Thomas Makatsoris

Commonly used chemotherapeutic agents in oncology/hematology practice, causing toxic peripheral neuropathy, include taxanes, platinum compounds, vinca alkaloids, proteasome inhibitors, and antiangiogenic/immunomodulatory agents. This review paper intends to put together and discuss the spectrum of chemotherapy-induced peripheral neuropathy (CIPN) characteristics so as to highlight areas of future research to pursue on the topic. Current knowledge shows that the pathogenesis of CIPN still remains elusive, mostly because there are several sites of involvement in the peripheral nervous system. In any case, it is acknowledged that the dorsal root ganglia of the primary sensory neurons are the most common neural targets of CIPN. Both the incidence and severity of CIPN are clinically under- and misreported, and it has been demonstrated that scoring CIPN with common toxicity scales is associated with significant inter-observer variability. Only a proportion of chemotherapy-treated patients develop treatment-emergent and persistent CIPN, and to date it has been impossible to predict high-and low-risk subjects even within groups who receive the same drug regimen. This issue has recently been investigated in the context of pharmacogenetic analyses, but these studies have not implemented a proper methodological approach and their results are inconsistent and not really clinically relevant. As such, a stringent approach has to be implemented to validate that information. Another open issue is that, at present, there is insufficient evidence to support the use of any of the already tested chemoprotective agents to prevent or limit CIPN. The results of comprehensive interventions, including clinical, neurophysiological, and pharmacogenetic approaches, are expected to produce a consistent advantage for both doctors and patients and thus allow the registration and analysis of reliable data on the true characteristics of CIPN, eventually leading to potential preventive and therapeutic interventions.

More than half of patients with KRAS-wild type advanced colorectal cancer (CRC) fail anti-EGFR monoclonal antibodies. We studied EGFR-axis messenger RNA (mRNA) expression and RAS, RAF, PIK3CA mutations in order to identify additional biomarkers of cetuximab efficacy. Previously genotyped (KRAS, NRAS, BRAF, PIK3CA mutations) formalin-fixed paraffin-embedded tumour biopsies of 226 cetuximab-treated CRC patients (1st to 3rd line therapy) were assessed for mRNA expression of epidermal growth factor receptor (EGFR) and its ligands EGF, Transofrming Growth Factor-a (TGFA), Amphiregulin (AREG) and Epiregulin (EREG) with real time quantitative PCR. Mutations were detected in 72 (31.9%) tumours for KRAS, in 6 (2.65%) for BRAF, in 7 (3.1%) for NRAS and in 37 (16.4%) for PIK3CA. Only PIK3CA mutations occasionally coexisted with other gene mutations. In univariate analysis, prognostic significance for survival ( from metastases until death) was seen for BRAF mutations (Hazard Ratio HR 8.1, 95% CI 3.4-19), codon 12-only KRAS mutations (HR 1.62, 95% CI 1.1-2.4), high AREG mRNA expression only in KRAS wild type CRC (HR 0.47, 95% CI 0.3-0.7) and high EREG mRNA expression irrespective of KRAS mutation status (HR 0.45, 95% CI 0.28-0.7). EREG tumoural mRNA expression was significantly associated with a 2.26-fold increased likelihood of objective response to cetuximab therapy (RECIST 1.1). In multivariate analysis, favourable predictive factors were high AREG mRNA in KRAS wild type tumours, high EREG mRNA, low Ephrin A2 receptor mRNA. Cetuximab-treated patients with AREG-low KRAS wild type CRC fared very poorly, their survival being similar to KRAS mutant CRC. Patients with KRAS codon 13 or other non-codon 12 mutations had a median survival (30 months, 95% CI 20–35) similar to that of patients with KRAS wild-type (median survival 29 months, 95% CI 25–35), in contrast to patients with KRAS codon 12 mutations who fared worse (median survival 19 months, 95% CI 15–26). BRAF and codon 12 KRAS mutations predict for adverse outcome of CRC patients receiving cetuximab. AREG mRNA reflects EGFR signalling in KRAS wild type tumours, predicting for cetuximab efficacy when high and failure when low. EREG may have a prognostic role independent of KRAS mutation.

Metronomic chemotherapy is considered an anti-angiogenic therapy that involves chronic administration of low-dose chemotherapy at regular short intervals. We investigated the optimal metronomic dose of oral vinorelbine when given as monotherapy in patients with metastatic cancer. Patients with recurrent metastatic breast (BC), prostate (PC) or non-small cell lung cancer (NSCLC) and adequate organ functions were randomly assigned to 30, 40 or 50 mg vinorelbine, taken orally three times a week. Treatment continued until disease progression, unacceptable toxicity, withdrawal of consent or maximum 24 months. Primary endpoint was time-to-treatment failure (TTF) and secondary were progression-free survival (PFS), toxicity, changes in blood concentrations of angiogenesis-associated biomarkers and pharmacokinetics. Seventy-three patients were enrolled. Four-month TTF rate did not differ between the three arms: 25.9% (11.1%-46.2% 95% Confidence Interval), 33.3% (15.6%-55.3%) and 18.2% (5.2%-40.3%) for the 30 mg, 40 mg and 50 mg arms (p-value = 0.56). Objective response was seen in 2 patients with NSCLC (treated at 30 and 50 mg respectively), one with BC (at 40 m g) and one with PC (at 50 mg) and lasted from 4 to 100 weeks, with maximum response duration achieved at 50 mg. Adverse events were mild and negligible and did not differ between the three arms. Blood levels of vinorelbine reached steady state from the second week of treatment and mean values for the 30, 40 and 50 mg were respectively 1.8 ng/ml (SD 1.10), 2.2 ng/ml (SD 1.87) and 2.6 ng/ml (SD 0.69). Low pre-treatment blood concentrations of FGF2 and IL8 predicted favorable response to therapy (p values 0.02 and 0.006, respectively), while high levels of TEK gene transcript predicted treatment resistance. Considering the antitumor activity and response duration, the negligible toxicity of the highest dose investigated and the lack of drug accumulation over time, we suggest that 50 mg given three times a week is the optimal dose for metronomic oral vinorelbine. Further investigation of metronomic oral vinorelbine (MOVIN) at this dose is warranted in combination with conventional chemotherapy regimens and targeted therapies. Clinicaltrials.gov NCT00278070

The ubiquitin-proteasome system (UPS) plays a pivotal role in tumorigenesis. Components of the UPS have recently been implicated in breast cancer progression. In the present study, we sought to explore the prognostic and/or predictive significance of UBE2C messenger RNA (mRNA) expression on disease-free survival (DFS) and overall survival (OS) in high-risk operable breast cancer patients.Five hundred and ninety-five high-risk breast cancer patients were treated in a two-arm trial evaluating postoperative, dose-dense sequential chemotherapy with epirubicin followed by CMF (cyclophosphamide, methotrexate and 5-fluorouracil) with or without paclitaxel (Taxol). RNA was extracted from 313 formalin-fixed primary tumor tissue samples followed by one-step quantitative RT-PCR for assessment of mRNA expression of UBE2C.High UBE2C mRNA expression was associated with poor DFS (Wald's P = 0.003) and OS (Wald's P = 0.005). High tumor grade, as well as high Ki67 protein expression, was more frequent in the high-expression group of UBE2C. Results of the Cox multivariate regression analysis revealed that high UBE2C mRNA expression remained an independent adverse prognostic factor for relapse (P = 0.037) and death (P = 0.05).High UBE2C mRNA expression was found to be of adverse prognostic significance in high-risk breast cancer patients. These findings need to be validated in larger cohorts.

We conducted a randomized, open-label, controlled trial to assess the efficacy of oxcarbazepine for prophylaxis against oxaliplatin-induced peripheral neuropathy (OxIN). Thirty-two patients with colon cancer received 12 courses of the FOLFOX-4 regimen and were randomly assigned to receive oxcarbazepine (600 mg BID) or chemotherapy without oxcarbazepine. The incidence of OxIN was strikingly decreased in patients receiving oxcarbazepine (31.2% vs 75%). Oxcarbazepine may prevent OxIN symptoms. Further larger placebo-controlled trials are warranted to confirm our results.

The current prospective study sought to trace the incidence and severity of oxaliplatin-induced peripheral neuropathy (OXLIPN) and to determine its clinical and electrophysiological pattern.Twenty-five adult patients scheduled to be treated with 12 courses of the oxaliplatin-based regimen, FOLFOX-4, for metastatic colon cancer participated in this study. Patients were clinically and electrophysiologically monitored at baseline and followed-up during chemotherapy. The severity of OXLIPN was summarized by means of a modified Total Neuropathy Score (TNS).Evidence of OXLIPN was disclosed in 16 of the 25 patients (64%). The mean TNS values for patients manifesting some grade of OXLIPN were 13.9 +/- 5.8 (range 7-28). All longitudinal comparisons concerning the motor conduction parameters failed to reach significance. By contrast, comparisons of the median changes at baseline and each of the follow-up studies revealed significant decrease in all sensory action potentials examined.Our results indicate that the majority of patients treated with the FOLFOX-4 regimen would manifest an axonal, predominately sensory peripheral neuropathy, of mild to moderate severity.

The aim was to compare two standard chemotherapy regimens combined with bevacizumab as first-line treatment in patients with metastatic colorectal cancer. Patients previously untreated for metastatic disease were randomized in: group A (irinotecan, capecitabine, bevacizumab, every 3 weeks; XELIRI-bevacizumab) and group B (irinotecan, leucovorin, fluorouracil, bevacizumab, every 2 weeks; FOLFIRI-bevacizumab). Primary endpoint was progression-free survival (PFS). Plasma concentrations of nitric oxide, osteopontin, TGF-β1 and VEGF-A were measured at baseline and during treatment. Among 285 eligible patients, 143 were randomized to group A and 142 to group B. Fifty-five patients (38.5%) in group A and 57 (40.1%) in group B responded (p = 0.81). After a median follow-up of 42 months, median PFS was 10.2 and 10.8 months (p = 0.74), while median OS was 20.0 and 25.3 months (p = 0.099), for groups A and B, respectively. Most frequent grade 3–4 toxicities (group A vs group B) were neutropenia (13% vs 22%, p = 0.053) and diarrhea (19% vs 11%, p = 0.082). Baseline plasma osteopontin concentrations demonstrated prognostic significance for both PFS and OS. This trial did not show significant differences in efficacy between the groups. However, the toxicity profile was different. Baseline plasma osteopontin concentrations demonstrated independent prognostic significance. (Registration number: ACTRN12610000270011)

The aim of the trial was to compare two active adjuvant chemotherapy regimens in patients with early stage colorectal cancer (CRC). Patients were assigned to oxaliplatin, leucovorin and 5-FU for 12 cycles (group A, FOLFOX6) or oxaliplatin and capecitabine for eight cycles (group B, CAPOX). Primary endpoint was disease-free survival (DFS). Tumors were classified as mismatch repair proficient (pMMR) or deficient (dMMR) according to MLH1, PMS2, MSH2 and MSH6 protein expression. KRAS exon two and BRAF V600E mutational status were also assessed. Between 2005 and 2008, 441 patients were enrolled, with 408 patients being eligible. After a median follow-up of 74.7 months, 3-year DFS was 79.8 % (95 % CI 76.5–83.4) in the FOLFOX group and 79.5 % (95 % CI 75.9–83.1) in the CAPOX group (p = 0.78). Three-year OS was 87.2 % (95 % CI 84.1-91.1) in the FOLFOX and 86.9 % (95 % CI 83.4–89.9) in the CAPOX group (p = 0.84). Among 306 available tumors, 11.0 % were dMMR, 34.0 % KRAS mutant and 4.9 % BRAF mutant. Multivariate analysis showed that primary site in the left colon, earlier TNM stage and the presence of anemia at diagnosis were associated with better DFS and overall survival (OS), while grade one–two tumors were associated with better OS. Finally, a statistically significant interaction was detected between the primary site and MMR status (p = 0.010), while KRAS mutated tumors were associated with shorter DFS. However, the sample was too small for safe conclusions. No significant differences were observed in the efficacy of FOLFOX versus CAPOX as adjuvant treatment in high-risk stage II or stage III CRC patients, but definitive conclusions cannot be drawn because of the small sample size. ANZCTR 12610000509066 . Date of Registration: June 21, 2010.

The clinical relevance of mismatch repair (MMR) status in patients with nonmetastatic cancer across tumour types remains unclear. Our goal was to investigate the prognostic role of MMR deficiency in patients with stage I-III colorectal and endometrial cancer.Patients with nonmetastatic colorectal and endometrial cancer with tumour tissue available for analysis were identified through the Hellenic Cooperative Oncology Group (HeCOG)'s tumour repository. Patients had been referred to Departments of Medical Oncology affiliated with HeCOG. MMR protein expression was evaluated by immunohistochemistry. The primary outcome measure was overall survival (OS).From May 1990 to September 2012, 1158 patients with nonmetastatic colorectal (N = 991) and endometrial cancer (N = 167) were identified (median age: 64 years, men: 544). All patients with colorectal and 109 (65%) with endometrial cancer had received adjuvant treatment. MMR deficiency was observed in 114 (11.5%) of colorectal and 80 (47.9%) of endometrial tumours. More commonly deficient proteins were PMS2 (69 patients, 7%) and MLH1 (63 patients, 6.5%) in colorectal cancer and MSH2 (58 patients, 34.7%) in endometrial cancer. Colorectal MMR-deficient (dMMR) tumours were more likely to be right sided (65 % dMMR vs 27 % proficient MMR, pMMR; p < 0.001), high grade (31% vs 15%, χ2, p < 0.001) and with a mucinous component (64% vs 42%, p < 0.001). Endometrial dMMR tumours were more often of endometrioid histology (51.4 % endometrioid vs 20 % serous/clear cell, p = 0.020). Compared with MMR proficiency, MMR deficiency was associated with improved OS in patients with endometrial cancer (HR = 0.38, 95% CI 0.20 to 0.76, p = 0.006), but not in patients with colorectal cancer (HR = 0.73, 95% CI 0.49 to 1.09, p = 0.130). After adjusting for age, stage and grade, MMR deficiency maintained its favourable prognostic significance in patients with endometrial cancer (HR = 0.42, 95% CI 0.20 to 0.88, p = 0.021).DMMR was associated with improved outcomes in patients with nonmetastatic endometrial cancer, but not in patients with nonmetastatic colorectal cancer who received adjuvant chemotherapy.

Background Chemokines are important in cell migration and are thought to play a key role in metastasis. We explored the prognostic significance of C-X-C ligand-motif (CXCL) 12, CXCL13, and receptor (CXCR) 5 on disease-free survival (DFS) and overall survival (OS) in early breast cancer. Methods A total of 595 patients at high risk for early breast cancer were treated in a 2-arm trial (HE10/97) with dose-dense sequential epirubicin followed by cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) with or without paclitaxel. RNA was extracted from 321 formalin-fixed paraffin-embedded primary tumor tissue samples and quantitative reverse-transcriptase polymerase chain reaction was used to assess messenger RNA (mRNA) expression of CXCL12, CXCL13, and CXCR5; estrogen receptor; progesterone receptor (PgR); microtubule-associated protein tau and human epidermal growth factor receptor 2 (HER2). Results CXCL13 and CXCR5 were found to be negatively associated with estrogen receptor and microtubule-associated protein tau mRNA expression and with dense lymphocytic infiltration, and were positively associated with nuclear grade. Only CXCL13 was positively associated with HER2. Multivariate analysis revealed an association between high CXCL13 mRNA expression and improved DFS (hazard ratio [HR] 0.48 [95% CI, 0.25-0.90]; Wald, P = .023) but not OS; whereas high CXCL12 expression was significantly associated with increased OS (HR 0.53 [95% CI, 0.33-0.85]; Wald, P = .009). In the HER2 mRNA overexpressing subgroup, high CXCL13 mRNA expression was associated with improved DFS (P < .001), whereas high CXCR5 was associated with increased DFS and OS (P = .004 and P = .049, respectively). Conclusions The CXCL13-CXCR5 axis is associated with classic determinants of poor prognosis, such as high grade, hormone receptor negativity, and axillary node involvement. Interestingly, this chemokine axis seems to be strongly associated with improved outcome in patients with HER2+ disease.

&lt;i&gt;Background:&lt;/i&gt; Oxaliplatin is a novel platinum derivative with established anti-tumor activity in colorectal cancer. Acute-onset hemolytic anemia and thrombocytopenia associated with this drug have rarely been reported and some of these cases have been severe or even fatal. &lt;i&gt;Case Report:&lt;/i&gt; This case report describes a patient who developed fever, chills, abdominal and back pain as well as sudden-onset severe thrombocytopenia, upper gastrointestinal bleeding and hemolysis immediately after treatment with oxaliplatin for metastatic colorectal cancer. The reaction appeared during the 14th cycle of chemotherapy. Corticosteroids and antihistamines were administered together with platelet transfusions. Over the next 2 days platelet count improved and the syndrome abated. The patient was discharged 4 days later. Furthermore, the reaction was accompanied by a strongly positive Coombs test and increased TNF-α and IL-10 serum levels which returned to normal following anti-inflammatory drug administration. &lt;i&gt;Conclusion:&lt;/i&gt; Physicians should be aware of the possibility of acute hematological emergencies following oxaliplatin administration.

This phase III study was designed to compare the combination paclitaxel (Taxol)-gemcitabine (PG) versus carboplatin-gemcitabine (CG) in patients with advanced inoperable non-small-cell lung cancer.Chemotherapy-naive patients with performance status of zero or one were randomized to gemcitabine 1 gm/m(2) on days 1 and 8 plus either paclitaxel 200 mg/m(2) on day 1 (arm A) or carboplatin at an area under the concentration-time curve of 6 mg on day 1 (arm B) every 3 weeks. Primary end point was overall survival (OS). Secondary end points included objective response (OR), time to progression and toxicity.A total of 512 patients were enrolled and 452 eligible (arm A, 225; arm B, 227) were analyzed. All characteristics were well balanced with the exception of vena cava obstruction symptoms and lymph node involvement. Median survival was 9.97 months [95% confidence interval (CI) 8.74-12.0] for group A and 10.49 (95% CI 9.04-11.94) for group B. There was no difference in the OS, 1-year survival, OR and TtP. However, statistically significant differences were seen in toxicity.The two regimens are equally active. Myelotoxicity is worse in the CG group whereas alopecia, myalgia and neurotoxicity worse in the PG group.

Platinum-based combinations are the standard second-line treatment for platinum-sensitive ovarian cancer (OC). This randomized phase II study was undertaken in order to compare the combination of carboplatin and pegylated liposomal doxorubicin (LD) with carboplatin and paclitaxel (CP) in this setting.Patients with histologically confirmed recurrent OC, at the time of or more than 6 months after platinum-based chemotherapy, were randomized to six cycles of CP (carboplatin AUC5 + paclitaxel 175 mg/m2, d1q21) or CLD (carboplatin AUC5 + pegylated LD 45 mg/m2, d1q28).A total of 189 eligible patients (CP 96, CLD 93), with a median age of 63 years, median Performance Status (PS) 0 and a median platinum free interval (PFI) of 16.5 months, entered the study. Discontinuation due to toxicity was higher in the CP patients (13.5% versus 3%, P = 0.016). The overall response rate was similar: CP 58% versus CLD 51%, P = 0.309 (Complete Response; CR 34% versus 23%) and there was no statistical difference in time-to-progression (TTP) or overall survival (OS; TTP 10.8 months CP versus 11.8 CLD, P = 0.904; OS 29.4 months CP versus 24.7 CLD, P = 0.454). No toxic deaths were recorded. Neutropenia was the most commonly seen severe toxicity (CP 30% versus CLD 35%). More frequent in CLD were severe thrombocytopenia (11% versus 2%, P = 0.016), skin toxicity and Palmar-plantar erythrodysesthesia (PPE) grade 1-2 (38% versus 9%, P< 0.001), while grade 3 neurotoxicity and alopecia were higher in CP (7% versus 0%, P = 0.029, 20% versus 5%, P = 0.003). PS and PFI were independent prognostic factors for TTP and OS.The combination of pegylated LD with carboplatin is effective, showing less neurotoxicity and alopecia than paclitaxel-carboplatin. It thus warrants a further phase III evaluation as an alternative treatment option for platinum-sensitive OC patients.Australian New Zealand Clinical Trials Registry: ACTRN12609000436279.

Colon cancer is a public health problem worldwide. Adjuvant chemotherapy after surgical resection for stage III colon cancer has been shown to improve both progression-free and overall survival, and is currently recommended as standard therapy. However, its value for patients with stage II disease remains controversial. When this study was designed 5-fluorouracil (5FU) plus leucovorin (LV) was standard adjuvant treatment for colon cancer. Irinotecan (CPT-11) is a topoisomerase I inhibitor with activity in metastatic disease. In this multicenter adjuvant phase III trial, we evaluated the addition of irinotecan to weekly 5FU plus LV in patients with stage II or III colon cancer. The study included 873 eligible patients. The treatment consisted of weekly administration of irinotecan 80 mg/m2 intravenously (IV), LV 200 mg/m2 and 5FU 450 mg/m2 bolus (Arm A) versus LV 200 mg/m2 and 5FU 500 mg/m2 IV bolus (Arm B). In Arm A, treatments were administered weekly for four consecutive weeks, followed by a two-week rest, for a total of six cycles, while in Arm B treatments were administered weekly for six consecutive weeks, followed by a two-week rest, for a total of four cycles. The primary end-point was disease-free survival (DFS) at three years. The probability of overall survival (OS) at three years was 0.88 for patients in Arm A and 0.86 for those in Arm B, while the five-year OS probability was 0.78 and 0.76 for patients in Arm A and Arm B, respectively (P = 0.436). Furthermore, the probability of DFS at three years was 0.78 and 0.76 for patients in Arm A and Arm B, respectively (P = 0.334). With the exception of leucopenia and neutropenia, which were higher in patients in Arm A, there were no significant differences in Grades 3 and 4 toxicities between the two regimens. The most frequently recorded Grade 3/4 toxicity was diarrhea in both treatment arms. Irinotecan added to weekly bolus 5FU plus LV did not result in improvement in disease-free or overall survival in stage II or III colon cancer, but did increase toxicity. Australian New Zealand Clinical Trials Registry: ACTRN12610000148077

Breast cancer generally develops in older women and its incidence is continuing to increase with increasing age of the population. The pathology and biology of breast cancer seem to be different in the elderly, often resulting in the undertreatment of elderly patients and thus in higher rates of recurrence and mortal-ity. The aim of this review is to describe the differences in the biology and treatment of early breast cancer in the elderly as well as the use of geriatric assessment methods that aid decision-making. Provided there are no contraindications, the cornerstone of treatment should be surgery, as the safety and efficacy of surgical resection in elderly women have been well documented. Because most breast cancers in the elderly are hormone responsive, hormonal therapy remains the mainstay of systemic treatment in the adjuvant setting. The role of chemotherapy is limited to patients who test negative for hormone receptors and demonstrate an aggressive tumor profile. Although the prognosis of breast cancer patients has generally improved during the last few decades, there is still a demand for evidence-based optimization of therapeutic interventions in older patients.

Abstract Objective To assess: (i) the prevalence, and clinical and imaging characteristics of immune checkpoint inhibitor (ICI)-induced musculoskeletal immune-related adverse events (ir-AEs) in a prospective manner and (ii) whether serum levels of cytokines associated with the Th1/Th2/Th17 response are differentially expressed in patients with and without musculoskeletal Ir-AEs. Methods All patients treated with ICI who developed musculoskeletal manifestations were referred to the Rheumatology Department, and an MRI of the involved area(s) was performed. Results During the study period, a total of 130 patients were treated with ICIs. Of these, 10 (7.7%) developed ICI-induced Ir-AEs. The median time from ICI treatment since development of symptoms was 2.5 months. Three different patterns of musculoskeletal manifestations were found: (i) prominent joint involvement (n = 3); (ii) prominent ‘periarticular’ involvement (n = 4). These patients had diffuse swelling of the hands, feet or knees. MRI depicted mild synovitis with more prominent myositis and/or fasciitis in the surrounding tissues in all cases; (iii) myofasciitis (n = 3). Clinically, these patients presented with pain in the knee(s)/thigh(s), whereas MRI depicted myofasciitis of the surrounding muscles. Patients with musculoskeletal ir-AEs had significantly higher oncologic response rates compared with patients not exhibiting musculoskeletal ir-AEs (50% vs 12.5%, respectively, P = 0.0016). Cytokine levels associated with a Th1/Th2/Th17 response were similar between patients with and without musculoskeletal ir-AEs. Overall, symptoms were mild/moderate and responded well to treatment, with no need for ICI discontinuation. Conclusion In our cohort, ICI-induced musculoskeletal manifestations developed in 7.7% of patients. Imaging evidence of myofasciitis was found in most patients, indicating that the muscle/fascia is more frequently involved than the synovium.

Bevacizumab, an antibody neutralizing Vascular Endothelial Growth Factor (VEGF), is licensed for the management of patients with advanced colon cancer. However, tumor biomarkers identifying the molecular tumor subsets most amenable to angiogenesis modulation are lacking.We profiled expession of 24526 genes by means of whole genome 24 K DASL (c-DNA-mediated, Annealing, Selection and Ligation) arrays, (Illumina, CA) in 16 bevacizumab-treated patients with advanced colon cancer (Test set). Genes with correlation to 8-month Progression-free status were studied by means of qPCR in two independent colon cancer cohorts: 49 patients treated with bevacizumab + chemotherapy (Bevacizumab qPCR set) and 72 patients treated with chemotherapy only (Control qPCR set). Endpoints were best tumor response before metastasectomy (ORR) and progression-free survival (PFS).Five genes were significantly correlated to 8-month progression-free status in the Test set: overexpression of KLF12 and downregulation of AGR2, ALDH6A1, MCM5, TFF2. In the two independent datasets, irinotecan- or oxaliplatin-based chemotherapy was administered as first-line treatment and metastasectomies were subsequently applied in 8-14% of patients. No prognostically significant gene classifier encompassing all five genes could be validated in the Bevacizumab or Control qPCR sets. The complex gene expression profile of all-low tumor (ALDH6A1 + TFF2 + MCM5) was strongly associated with ORR in the Bevacizumab qPCR set (ORR 85.7%, p = 0.007), but not in the Control set (ORR 36.4%, p = 0.747). The Odds Ratio for response for the all-low tumor (ALDH6A1 + TFF2 + MCM5) profile versus any other ALDH6A1 + TFF2 + MCM5 profile was 15 (p = 0.018) in the Bevacizumab qPCR set but only 0.72 (p = 0.63) in the Control set. The tumor expression profile of (KLF12-high + TFF2-low) was significantly associated with PFS only in the Bevacizumab qPCR set: bevacizumab-treated patients with (KLF12-high + TFF2-low) tumors had superior PFS (median 14 months, 95% CI 2-21) compared to patients with any other (KLF12 + TFF2) expression profile (median PFS 7 months, 95% CI 5-10, p = 0.021). The Hazard Ratio for disease progression for (KLF12-high + TFF2-low) versus any other KLF12 + TFF2 expression profile was 2.92 (p = 0.03) in the Validation and 1.29 (p = 0.39) in the Control set.Our «three-stage» hypothesis-generating study failed to validate the prognostic significance of a five-gene classifier in mCRC patients. Exploratory analyses suggest two gene signatures that are potentially associated with bevazicumab benefit in patients with advanced colon cancer.

Patients with colorectal cancer (CRC) with wild-type KRAS mutations are often treated with the endothelial growth factor receptor (EGFR) monoclonal antibody cetuximab. Despite the presence of a specific molecular target, most patients still do not derive benefit from this biological treatment. Our study explores the role of ephrin A2 (EphA2) receptor expression and of EGFR pathway mediators as predictors of cetuximab benefit.Formalin-fixed paraffin-embedded (FFPE) tumor biopsy samples from 226 cetuximab-treated patients with CRC were studied for mRNA expression of insulin growth factor binding protein 2 (IGFBP2), insulin growth factor receptor 1 (IGF1R), cMET, EphA2, human epidermal growth factor receptor 2 (HER2), HER3, and HER4 by means of TaqMan reverse-transcribed polymerase chain reaction (RT-PCR).Of the 226 patients evaluable for exploratory analysis, 222 had complete data from follow-up visits. The univariate analysis revealed the following significant adverse prognostic factors for risk of death: high EphA2 mRNA levels (hazard ratio [HR], 1.61; P = .015), high HER2 mRNA levels (HR, 1.51; P = .045), and high IGF1R mRNA levels (HR, 1.56; P = .021). Low EphA2 tumor expression was significantly associated with objective response to cetuximab therapy. In multivariate analysis of a broad biomarker panel, factors with independent prognostic value included EphA2 mRNA levels (HR, 1.67; P = .029), high amphiregulin (AREG) mRNA levels in KRAS wild-type tumors (HR, 0.17; P < .0001), and high epiregulin (EREG) mRNA levels (HR, 0.38; P = .006).High EphA2 receptor expression in CRC was associated with a worse outcome in patients treated with cetuximab-based therapy. Prospective validation in treated and control patients is required to dissect the predictive from prognostic role in advanced CRC.

Germline mutations in the BRCA1 and BRCA2 genes contribute to approximately 18% of hereditary ovarian cancers conferring an estimated lifetime risk from 15% to 50%. A variable incidence of mutations has been reported for these genes in ovarian cancer cases from different populations. In Greece, six mutations in BRCA1 account for 63% of all mutations detected in both BRCA1 and BRCA2 genes. This study aimed to determine the prevalence of BRCA1 mutations in a Greek cohort of 106 familial ovarian cancer patients that had strong family history or metachronous breast cancer and 592 sporadic ovarian cancer cases. All 698 patients were screened for the six recurrent Greek mutations (including founder mutations c.5266dupC, p.G1738R and the three large deletions of exon 20, exons 23-24 and exon 24). In familial cases, the BRCA1 gene was consequently screened for exons 5, 11, 12, 20, 21, 22, 23, 24. A deleterious BRCA1 mutation was found in 43/106 (40.6%) of familial cancer cases and in 27/592 (4.6%) of sporadic cases. The variant of unknown clinical significance p.V1833M was identified in 9/698 patients (1.3%). The majority of BRCA1 carriers (71.2%) presented a high-grade serous phenotype. Identifying a mutation in the BRCA1 gene among breast and/or ovarian cancer families is important, as it enables carriers to take preventive measures. All ovarian cancer patients with a serous phenotype should be considered for genetic testing. Further studies are warranted to determine the prevalence of mutations in the rest of the BRCA1 gene, in the BRCA2 gene, and other novel predisposing genes for breast and ovarian cancer.

Background Although host immune response is an emerging prognostic factor for colorectal cancer, there is no consensus on the optimal methodology, surrogate markers or tissue for study. Patients and Methods Tumour blocks were prospectively collected from 344 patients with stage II/III colorectal cancer (CRC) treated with adjuvant chemotherapy. Whole section lymphocytic infiltration was studied along with mRNA expression of CD3Z, CD8, CD4, CXCL9, CXCL13, IGHM, FOXP3, SNAI2 and ESR1 by qRT-qPCR in tissue microarray (TMA) cores from the centre of tumour, invasive margin and adjacent normal mucosa. Results Lymphocytic infiltration, deficient MMR (10.9%), KRAS (40.7%) and BRAF (4.9%) mutations or single mRNA gene expression were not prognostic. Tumour ESR1 gene expression (Hazard Ratio [HR] for relapse 2.33, 95% CI 1.35-4.02; HR for death 1.74, 95% CI 1.02-2.97) and absence of necrosis (HR for relapse 1.71, 95% CI 1.05-2.71; HR for death 1.98, 95% CI 1.14-3.43) were adverse prognostic features. We used CD3Z and CD8 expression in order to devise the mRNA-based Immune Score (mIS) and proceeded to partitioning analysis in 267 patients, with age, stage, tumour site (Right vs Left CRC), KRAS mutation and tumour mIS as input factors. Only in patients with stage III right-sided colon cancer, a low immune response was associated with inferior disease-free survival (mIS-low, HR for relapse 2.28, 95% CI 1.05-8.02). No prognostic significance was seen for tumour mIS in any other stage or site of CRC, or for a similar mIS score derived from adjacent normal mucosa. Independent adverse prognostic significance was retained in multivariable analysis for absence of necrosis, tumour ESR1 expression in all patients and low tumour mIS in stage III right-sided CRC. Conclusions In localised CRC, mRNA-based CD3Z/CD8 profiling of tumour immune response may have stage, site and tissue-specific prognostic significance, along with ESR1 expression. Trial Registration ANZCTR.org.au ACTRN12610000509066

In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.

Despite considerable improvement in the management of colon cancer, there is a great deal of variation in the outcomes among European countries, and in particular among different hospital centers in Greece and Cyprus. Discrepancy in the approach strategies and lack of adherence to guidelines for the management of colon cancer may explain the situation. The aim was to elaborate a consensus on the multidisciplinary management of colon cancer, based on European guidelines (ESMO and EURECCA), and also taking into account local special characteristics of our healthcare system. Following discussion and online communication among members of an executive team, a consensus was developed. Statements entered the Delphi voting system on two rounds to achieve consensus by multidisciplinary international experts. Statements with an agreement rate of ≥80% achieved a large consensus, while those with an agreement rate of 60-80% a moderate consensus. Statements achieving an agreement of <60% after both rounds were rejected and not presented. Sixty statements on the management of colon cancer were subjected to the Delphi methodology. Voting experts were 109. The median rate of abstain per statement was 10% (range: 0-41%). In the end of the voting process, all statements achieved a consensus by more than 80% of the experts. A consensus on the management of colon cancer was developed by applying the Delphi methodology. Guidelines are proposed along with algorithms of diagnosis and treatment. The importance of centralization, care by a multidisciplinary team, and adherence to guidelines is emphasized.

Alternative splicing of vascular endothelial growth factor A (VEGFA) results in VEGFAxxxb antiangiogenic isoforms that fail to activate angiogenesis. Bevacizumab, widely used in patients with metastatic colorectal cancer (CRC), binds both VEGFA and VEGFAxxxb isoforms.Formalin-fixed, paraffin-embedded primary tumors from metastatic CRC patients treated with first-line FOLFIRI (leucovorin, 5-fluorouracil, irinotecan, and oxaliplatin) + bevacizumab (n = 285) or FOLFIRI only (n = 75) were collected. The relative expression of VEGFA121a, 121b, 145a, 145b, 165a, and 165b was assessed with custom TaqMan-MGB assays and quantitative PCR.At a median follow-up of 101.5 months, left-sided primary CRC was a favorable prognosticator (median survival, 29.2 vs. 18.2 months; P = .015). Positive high VEGFA145b was an unfavorable factor for progression-free survival (PFS; hazard ratio [HR] = 1.66; 95% confidence interval [CI], 1.13-2.44; P = .009) in patients who received FOLFIRI + bevacizumab, without prognostic significance in FOLFIRI-only patients (HR = 0.70; 95% CI, 0.34-1.44; P = .33). The adverse effect on PFS of 145b was more pronounced in patients with right-sided colon cancer (HR = 2.62; 95% CI, 1.35-5.12; P = .005), especially in those who received bevacizumab (HR = 2.85; 95% CI, 1.31-6.21; P = .008). In patients with right-sided colon primary tumors, isoform 121b correlated with inferior PFS (HR = 1.73; 95% CI, 0.94-3.18; P = .076) and overall survival (OS; HR = 2.0; 95% CI, 1.08-3.72; P = .028). In patients with left-sided primary tumors, positive high 165b correlated with superior PFS (HR = 0.76; 95% CI, 0.59-0.99; P = .044) and OS (HR = 0.68; 95% CI, 0.52-0.90; P = .006). At multivariate analysis, right-sided primary tumor was associated with inferior PFS (HR = 1.28; 95% CI, 1.00-1.64), while 145b consistently retained predictive significance for lack of benefit in PFS with bevacizumab (HR = 1.71; 95% CI, 1.16-2.53). Multivariate analysis for OS showed that VEGFA165b expression was favorable in patients with left-sided but unfavorable in patients with right-sided primary tumors (Pinteraction < .001).The antiangiogenic isoform VEGFA145b messenger RNA may predict resistance to bevacizumab. Differences in biological relevance and prognostic significance of various VEGFA isoforms were found for right- versus left-sided primary tumors.

Capecitabine and oxaliplatin are both effective and well-tolerated monotherapies for the treatment of advanced colorectal cancer (CRC). Oxaliplatin has also been shown to be very effective when combined with 5-FU/LV in the first-line setting.Assess the efficacy and safety of capecitabine plus oxaliplatin (XELOX) in patients with previously untreated advanced CRC.Fifty-three patients with measurable disease received capecitabine 1,000 mg/m2 twice daily on d 1-14 and oxaliplatin 130 mg/m2 on d 1, every 3 wk. Of these, 52 were evaluable for safety and 49 for antitumor response.There was a low rate of grade 1/2 adverse events; grade 3/4 events included leukopenia (10%), neutropenia (6%), thrombocytopenia (2%), nausea/vomiting (4%), and diarrhea (4%). The overall response rate was 39% (95% CI, 25-54%) and median time to disease progression was 7.8 mo.XELOX is an active and well-tolerated first-line treatment for advanced CRC. Randomized phase III studies are ongoing to compare XELOX with FOLFOX in view of the comparable efficacy and safety but superior convenience of XELOX therapy.

The aim of this study was to determine the safety and activity of vinorelbine in combination with estramustine in men with androgen-independent metastatic prostate cancer.Twenty-five men with androgen-independent metastatic prostate cancer were treated with the combination of vinorelbine and estramustine. Vinorelbine 25 mg/m(2) was administered by intravenous bolus on Days 1 and 8. Estramustine 140 mg was administered three times a day by mouth on Days 1 through 14. Treatment was repeated every 21 days.A total of 132 cycles of treatment were administered. The median number of cycles per patient was 5 (range: 1-16). Mild Grade 1 or 2 gastrointestinal toxicity and fatigue were the most common adverse effects. Hematologic toxicity was minimal. Treatment resulted in a sustained > 50% decrease in serum prostate-specific antigen (PSA) in 6 of 25 patients (24% of patients; 95% confidence interval (CI) 9-45%). The median duration of PSA response was 10 weeks (range: 3-39 weeks). Of the five men with bidimensionally measurable disease, none achieved a complete or partial response. There were no documented improvements in post-treatment bone scans. Median overall survival time was 14.1 months.The combination of vinorelbine and estramustine is a well-tolerated and modestly active regimen in men with androgen-independent metastatic prostate cancer.

BackgroundThere has been limited research examining the efficacy of providing written information to cancer patients in southern and eastern European countries. This study investigated the impact of a booklet about chemotherapy on patient satisfaction, quality of life (QoL) and emotional distress, and assessed booklet use.Patients and methodsA total of 145 Greek cancer outpatients prior to commencing chemotherapy completed a questionnaire and were randomized to receive (n = 72) or not receive (n = 73) the booklet. All patients completed the second questionnaire before the following cycle of chemotherapy.ResultsBaseline characteristics were well balanced between the two groups. Experimental group patients reported being significantly more satisfied with the information received and care overall than those in the control group, felt significantly more and better informed, and perceived the information received as being clearer and detailed. The intervention produced no benefits in terms of anxiety, depression or QoL. The booklet was read by almost all patients and to a great extent by significant others. The majority considered the booklet useful to read and helpful in recalling chemotherapy-related information.ConclusionsThe current results provide further evidence on the efficacy of information-giving interventions in societies where disclosure of information to cancer patients still remains controversial.

Notch may behave as an oncogene or a tumor suppressor gene in lung cancer cells. Notch receptor undergoes cleavage by enzymes, including γ-secretase, generating the active Notch intracellular domain (NICD). The aim of the present study was to investigate the effect of DAPT, a γ-secretase inhibitor, in non-small cell lung cancer (NSCLC) cells, as well as the impact of epidermal growth factor (EGF) that is over-expressed by NSCLC cells, on Notch signaling. H23, A549, H661 and HCC827 human NSCLC cell lines were used, expressing various NICD and EGF receptor (EGFR) protein levels.DAPT decreased the number of H661 cells in a concentration-dependent manner, while it had a small effect on H23 and A549 cells and no effect on HCC827 cells that carry mutated EGFR. Notch inhibition did not affect the stimulatory effect of EGF on cell proliferation, while EGF prevented DAPT-induced NICD decrease in H23 and H661 cells. The type of cell death induced by DAPT seems to depend on the cell type.Our data indicate that inhibition of Notch cleavage may not affect cell number in the presence of EGFR mutations and that EGFR may affect Notch signalling suggesting that a dual inhibition of these pathways might be promising in NSCLC.

Background: The prognosis of patients with recurrent and/or metastatic head and neck cancer (HNC) is poor. Median survival of these patients following chemotherapy is in the range of 6 to 9 months. In the present randomized phase III trial we compared two new combinations containing new drugs with proven activity in phase II studies with patients with HNC.Patients and methods: From November 1999 until November 2004, 166 eligible patients with HNC were enrolled in the study. They were treated with paclitaxel 175 mg/m2 on day 1 and gemcitabine 1000 mg/m2 on days 1 and 8 every 3 weeks (group A, 85 patients) or with paclitaxel, as in group A, and pegylated liposomal doxorubicin 40 mg/m2 on day 1 every 4 weeks (group B, 81 patients).Results: There was no significant difference in response rate (20% versus 29%, P = 0.21), time to disease progression (median; 4.4 months versus 6.0 months, P = 0.09) and survival (median; 8.6 months versus 11.05 months, P = 0.25). Both regimens were generally well tolerated. The most frequently reported side effect, apart from alopecia, was neutropenia. Overall, there was no significant difference in severe toxicity between the two treatment arms.Conclusions: The present study could not demonstrate a survival benefit with either regimen. Both treatments were well tolerated. Randomized studies comparing each of the two regimens with standard chemotherapy are warranted.

Current evidence indicates that angiogenesis plays an important role in the pathogenesis of several malignancies, including breast cancer. Bevacizumab is a monoclonal antibody that targets the vascular endothelial growth factor (VEGF). Recent clinical data have demonstrated that the addition of bevacizumab to first-line chemotherapy improves the progression-free survival (PFS) of patients with advanced breast cancer. This review presents an update on the clinical studies evaluating the role of bevacizumab in combination with chemotherapy, as well as other agents, both in advanced and early disease. Moreover, although no definitive biomarkers have been identified so far, we provide current data regarding potentially useful predictive factors for treatment with bevacizumab. In addition, we review the suggested mechanisms that lead to resistance to VEGF targeted therapies and we present recent data with respect to the toxicity of bevacizumab.

A growing number of studies has shed light on the role of the NF-κΒ in non-small-cell lung cancer (NSCLC). To address the significance of major effectors of the NF-κΒ alternative pathway, we investigated the relationship between NF-κΒ2, RelB, NIK and Bcl3 expression (mRNA and protein) and the clinical outcome of NSCLC patients. NF-κΒ2, RelB, NIK and Bcl3 protein expression levels were assessed by immunohistochemistry in tissue samples from 151 NSCLC patients who had curative resection. mRNA levels were also evaluated in 69 patients using quantitative real-time PCR. Although all studied proteins were overexpressed in NSCLC (P < 0.001 for all), only RelB mRNA levels were strongly increased in cancerous specimens compared to tumor-adjacent non-neoplastic tissues (P = 0.009). Moreover, NF-κB2, RelB and Bcl3 expression was associated with overall survival (OS). In particular, cytoplasmic and mRNA expression of RelB was related to 5-year OS (P = 0.014 and P = 0.006, respectively). Multivariate analysis also showed that Bcl3 expression (nuclear and cytoplasmic) was associated with increased 5-year OS (P = 0.002 and P = 0.036, respectively). In addition, higher Bcl3 mRNA levels were associated with inferior OS in stages I & II and improved OS in stages III and IV after 5-year follow-up (P = 0.004 and P = 0.001, respectively). Furthermore, stage I patients with lower NF-κB2 mRNA levels had better 5-year survival in univariate and multivariate analysis (P = 0.031 and P = 0.028, respectively). Interestingly, RelB expression (cytoplasmic and mRNA) was inversely associated with relapse rates (P = 0.027 and P = 0.015, respectively), while low NIK cytoplasmic expression was associated with lower relapse rates (P = 0.019). Cytoplasmic NIK expression as well as NF-κB2/ Bcl3 detection was associated with lymph node infiltration (P = 0.039 and P = 0.014, respectively). The present study confirms the deregulation of the NF-κB alternative pathway in NSCLC and also demonstrates the importance of this pathway in prognosis, recurrence and infiltration of regional lymph nodes.

Purpose: To report a case of a 73-year-old man who presented with decreased visual acuity due to bilateral macular edema after paclitaxel administration for prostate cancer. Methods: The ophthalmic evaluation consisted of medical and ocular history, Best Corrected Visual Acuity, slit-lamp biomicroscopy and Spectral-domain optical coherence tomography / Fluorescein Angiography. Results: Optical Coherence Tomography and Fluorescein Angiography revealed silent cystoid macular edema. After consulting with the oncologist, the cessation of paclitaxel therapy was decided. The patient presented a gradual but steady resumption of the retinal edema, with complete restoration of normal retinal morphology and function within two months. The pathogenesis of the silent Cystoid Macular Edema (CME) is still unclear. Based on our case and a critical review of the previous observations and published data, we propose that the underlying cause of Taxane induced CME is the functional failure of Aquaporin mediated water transport at the level of retinal Intermediate and Deep capillary plexuses, and at lesser extent at the level of the Retinal Pigment Epithelium. Conclusion: Taxane induced silent CME should be attributed to the action of Taxanes on the microtubule guided aquaporin vesicles transport to the cell membrane. In our case of Taxane induced silent CME, withdrawal of the taxane was enough for complete recovery, and no additional treatment was needed.

Background/Aim: Early-stage colorectal cancer (CRC) carries a wide range of survival probabilities. Novel biomarkers in this setting are eagerly awaited. Cancer stem cells (CSCs) are considered one of the reasons for treatment failure. This study sought to determine whether activation of pathways governing the function of CSC9s could correlate with treatment outcomes. Materials and Methods: Tumor specimens from 325 patients were analyzed with immunohistochemistry (IHC) for Hedgehog and Notch pathway activation and results were correlated with prognosis. Results: Positive Notch3 protein expression was an unfavorable prognostic factor for disease-free survival (DFS) and overall survival (OS) (HR=2.43, p=0.024 and HR=2.56, p=0.028, respectively). Activation of the Shh pathway showed univariately longer DFS (HR=0.49, p=0.032). Possible crosstalk between the two pathways was indicated. No further associations between pathway activation and outcome were evident. Conclusion: Apart from Notch 3, activation of the pathways, as indicated by IHC expression of their components, did not result in differences in terms of DFS or OS.

Deregulation of the transcribed ultra-conserved regions (T-UCRs) Uc160, Uc283, and Uc346 has been reported in colorectal cancer (CRC) recently. Here, we investigated promoter methylation of these T-UCRs during the adenoma–carcinoma sequence and their clinical significance in CRC patients. Methylation levels were assessed in CRC, adenomas, infiltrated lymph nodes, and metastatic tissue specimens. In situ hybridization was performed in representative tissue specimens. T-UCRs expression levels were also evaluated in HT-29 colon cancer cells before and after the acquired resistance to 5-fluorouracil (5-FU) and oxaliplatin. A gradual increase in T-UCRs methylation levels from hyperplastic polyps to adenomas and to in situ carcinomas (ISC) and a gradual decrease from ISC to infiltrative and metastatic carcinomas was observed (p &lt; 0.001 for Uc160 and Uc283, p = 0.018 for Uc346). Uc160 and Uc283 methylation was associated with the grade of dysplasia in adenoma specimens (p = 0.034 and p = 0.019, respectively). Furthermore, higher Uc160 methylation, mainly in stage III and IV patients, was related to improved overall survival (OS) in univariate (p = 0.009; HR, 0.366) and multivariate analysis (p = 0.005; HR, 0.240). Similarly, higher methylation of Uc283 was associated with longer OS (p = 0.030). Finally, T-UCRs expression was significantly reduced in HT-29 cells after resistance to chemotherapy. This study suggests that promoter methylation of Uc160, Uc283, and Uc346 is altered during CRC development and that Uc160 and Uc283 methylation may have prognostic significance for CRC patients.

Expression of Transcribed Ultraconserved Regions (T-UCRs) is often deregulated in cancer. The present study assesses the expression and methylation of three T-UCRs (Uc160, Uc283 and Uc346) in colorectal cancer (CRC) and explores the potential of T-UCR methylation in circulating DNA for the detection of adenomas and adenocarcinomas. Expression levels of Uc160, Uc283 and Uc346 were lower in neoplastic tissues from 64 CRC patients (statistically significant for Uc160, p<0.001), compared to non-malignant tissues, while methylation levels displayed the inverse pattern (p<0.001, p=0.001 and p=0.004 respectively). In colon cancer cell lines, overexpression of Uc160 and Uc346 led to increased proliferation and migration rates. Methylation levels of Uc160 in plasma of 50 CRC, 59 adenoma patients, 40 healthy subjects and 12 patients with colon inflammation or diverticulosis predicted the presence of CRC with 35% sensitivity and 89% specificity (p=0.016), while methylation levels of the combination of all three T-UCRs resulted in 45% sensitivity and 74.3% specificity (p=0.013). In conclusion, studied T-UCRs' expression and methylation status are deregulated in CRC while Uc160 and Uc346 appear to have a complicated role in CRC progression. Moreover their methylation status appears a promising non-invasive screening test for CRC, provided that the sensitivity of the assay is improved.

Immunotherapy with immune checkpoint inhibitors (ICIs) has changed the therapeutic management of advanced non-small cell lung cancer (aNSCLC) over the last decade. However, there is an unmet need for clinically useful biomarkers in this patient subgroup. The aim of this study was to combine baseline clinical characteristics of aNSCLC patients, in the form of a scoring system, and to investigate its predictive and prognostic value in NSCLC patients treated with ICIs. A total of 112 patients with advanced (stages IIIA to IV) NSCLC, treated with nivolumab or pembrolizumab, were enrolled in this study. Patras Immunotherapy Score (PIOS) was developed based on four of the studied parameters (performance status (PS), body mass index (BMI), age, and lines of treatment (LOT), which were incorporated into our formula (PS × BMI/ LOT × age). PIOS score was strongly associated with best overall responses (BOR), with those patients having benefit/good response (stable disease (SD) or partial (PR) or complete response (CR), achieving a higher score compared to patients who developed progressive disease (PD) (p &lt; 0.001). Furthermore, PIOS score was associated with progression-free survival (PFS), since high-score patients had longer PFS (p &lt; 0.001, hazard ratio (HR) = 0.469). Moreover, PIOS was associated with post-immunotherapy overall survival (OS), with high-score patients having improved OS (log-rank p = 0.019). This study suggests that a combination of baseline parameters, which give rise to PIOS score, may predict the best response of NSCLC patients treated with anti-program cell death -1 (PD-1) monotherapy as well as it may have a potent prognostic value for PFS and post immunotherapy OS.

Abstract During the last decade, a growing number of publications implicate NF-kB2 in NSCLC pathogenesis. Here, we investigated the clinical relevance of NF-kB2 single nucleotide polymorphisms (SNPs) rs7897947, rs11574852 and rs12769316 in NSCLC and their association with NF-kB2 protein and mRNA levels. Our data show that TT (rs7897947T &gt;G ) and AA (rs12769316G &gt;A) genotypes were strongly associated with an increased risk for NSCLC (P = 0.019 and P = 0.003, respectively). Additionally, in multivariate analysis, TT (rs7897947T &gt;G ) homozygosity was associated with worse 2- and 3-year survival rates (P = 0.030 and P = 0.028, respectively), especially among patients with stages III/IV, who had worse 2, 3 and 5-year survival (P = 0.001, P = 0.022 and P = 0.035, respectively). In chemotherapy-treated patients, TT (rs12769316G &gt;A) homozygosity was also associated with worse 2- and 3-year survival compared to G allele carriers (P = 0.006 and P = 0.014, respectively). Furthermore, rs12769316 was correlated with survival outcome of stage I and II patients (P = 0.031 and P = 0.006, respectively). Interestingly, amongst the patients who developed metastases, A allele carriers had better 5-year survival (P = 0.020). In addition, rs12769316 was associated with NF-kB2 protein (P = 0.001) and mRNA expression (P = 0.017) as well as with tumor maximum diameter (P = 0.025). Overall, this study suggests that rs7897947 and rs12769316 are involved in NSCLC susceptibility, in treatment response and in clinical outcome.

An increasing number of studies implicates the NF-κB (Nuclear Factor of kappa light chain gene enhancer in B cells) alternative pathway in non-small-cell lung cancer (NSCLC). We assessed the clinical significance of CD40 (Tumor necrosis factor receptor superfamily member 5, TNFRSF5), BAFFR (B-cell activating factor receptor), RANK (Receptor activator of NF-κB) and LTβR (lymphotoxin β receptor) receptors, which activate the alternative pathway of NF-κB, in NSCLC. Evaluation of CD40, BAFFR, RANK and LTβR expression was performed based on the Cancer Genome Atlas (TCGA) and the Genotype-Tissue Expression (GTEx) datasets, while protein expression was assessed by immunohistochemistry in specimens from 119 operated NSCLC patients. CD40 gene overexpression was correlated with improved five-year overall survival (OS) (p < 0.001), while increased BAFFR and LTβR mRNA levels were associated with worse OS in patients with adenocarcinomas (p < 0.001 and p < 0.001, respectively). Similarly, patients with adenocarcinomas exhibited a negative correlation between membranous BAFFR protein expression in carcinoma cells and three- and five-year survival (p = 0.021; HR, 4.977 and p = 0.030; HR, 3.358, respectively) as well as between BAFFR protein overexpression in cancer-associated fibroblasts (CAFs) and two-year survival (p = 0.036; HR, 1.983). Patients with increased LTβR nuclear protein staining or stage II patients with lower cytoplasmic LTβR protein expression had worse five-year OS (p = 0.039 and p = 0.008, respectively). Moreover, CD40 protein expression in tumor infiltrating lymphocytes (TILs) and CAFs was positively associated with metastatic spread while BAFFR protein expression in CAFs was negatively associated with bone metastasis (p = 0.041). Our data suggests that CD40, BAFFR, RANK and LTβR play an important role in NSCLC and further supports the role of NF-κB alternative pathway in NSCLC.

A growing number of studies have shed light on the role of small extracellular vesicles (sEVs), including exosomes, in colorectal cancer (CRC). Available data regarding the clinical significance of molecular players in CRC, implicated in sEVs biogenesis, is limited. In this study, we assessed the expression of the most important genes which are implicated in sEVs biogenesis and their association with sEVs plasma levels, investigated with a double sandwich ELISA assay, as well as with the clinical outcome of patients with CRC. Our study shows that RAB27A, RAB27B, RAB2B, and RAB3B mRNA levels were lower in tumor tissues compared to tumor adjacent, non-malignant tissues (p < 0.001, p = 0.009, p = 0.011, and p < 0.001, respectively). In addition, high tumor expression of RAB27A, RAB27B, RAB9A, RAB11B, and STX1A was favorable of a 5-year survival (p = 0.038, p = 0.015, p = 0.008, p = 0.002, and p = 0.028, respectively). Furthermore, patients with adenomas had lower overall plasma sEVs concentrations, compared to healthy volunteers (p = 0.026), while no statistically significant differences were observed in the overall or tumor-derived plasma sEVs concentration (p = 0.885 and p = 0.330, respectively) of CRC patients. In conclusion, sEVs biogenesis has a potentially significant role in CRC, with RAB27A, RAB27B, RAB9A, RAB11B, and STX1A having a promising role in survival outcomes.

Vinorelbine and mitoxantrone have both been demonstrated to have significant antitumor activity in patients with breast cancer. The aim of this study was to evaluate the efficacy and safety of the combination as second or third line treatment in patients with metastatic breast cancer (MBC).Fifty-one previously treated patients with MBC were enrolled from October 2001 to May 2004 and 48 were eligible for evaluation. Median age was 59 years (range 33-82) and ECOG performance status was ≤2. Distant sites of metastasis were as follows: liver 64%, bone 49%, lung 36%, lymph nodes 6%, skin 4%, brain 2% and other sites 6%. All patients received vinorelbine 20 mg/m2, D1+8 and mitoxantrone 10 mg/m2 D8 every 21 days for 6 cycles.All eligible patients were analyzed for toxicity and response. Two patients (4%) achieved complete response and 12 (25.5%) partial response. The objective overall response rate was 29.5% (95% confidence interval [CI] 17 - 45), 9 (19%) patients had stable disease, 17 (36%) had progressive disease and 7 (15%) were non-evaluable. After a median follow up of 18 months, overall survival was 13 months (range 0.8 - 38+) and median time to disease progression was 5 months (range 1 - 32). A total of 280 cycles was delivered. The relative dose intensities of mitoxantrone and vinorelbine were 79% and 77%, respectively. Toxicities (grade III-IV) were as follows: leukopenia 18 (38%), neutropenia 21 (45%), thrombocytopenia 1 (2%), anemia 4 (8.5%), alopecia 2 (4%) and constipation 1 (2%). Febrile neutropenia was recorded in one patient. There were no treatment related deaths.The combination of mitoxantrone and vinorelbine is an effective regimen with manageable toxicity in pretreated patients with advanced breast cancer.

Th ere is discrepancy and failure to adhere to current international guidelines for the management of metastatic colorectal cancer (CRC) in hospitals in Greece and Cyprus.Th e aim of the present document is to provide a consensus on the multidisciplinary management of metastastic CRC, considering both special characteristics of our Healthcare System and international guidelines.Following discussion and online communication among the members of an executive team chosen by the Hellenic Society of Medical Oncology (HeSMO), a consensus for metastastic CRC disease was developed.Statements were subjected to the Delphi methodology on two voting rounds by invited multidisciplinary international experts on CRC.Statements reaching level of agreement by ≥80% were considered as having achieved large consensus, whereas statements reaching 60-80% moderate consensus.One hundred and nine statements were developed.Ninety experts voted for those statements.Th e median rate of abstain per statement was 18.5% (range: 0-54%).In the end of the process, all statements achieved a large consensus.Th e importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.R0 resection is the only intervention that may off er substantial improvement in the oncological outcomes.

The current study aimed to assess the viability of sympathetic sudomotor fibers in cancer patients treated with cisplatin or paclitaxel‐based chemotherapy and to ascertain whether this method could contribute to the diagnostic sensitivity of conventional techniques. Sympathetic skin response (SSR) from the hand and sole of 23 cancer patients (nine females and 14 males, mean age 62.4 ± 10.5 years) was recorded unilaterally before and after chemotherapy with six courses of cumulative cisplatin or paclitaxel containing regimens. Clinical and electrophysiological data were also collected and correlated with the SSR results. Twenty‐three healthy subjects served as controls. SSR abnormalities were only present in patients with evidence of peripheral neuropathy assessed by conventional nerve conduction techniques. Three patients had absent SSR in the upper limb whilst six patients had absent SSR both in the upper and lower limbs. In the upper limb, the mean SSR latency was not significantly altered through time ( P = 0.086). In the lower limb the mean delay from baseline to follow‐up was significantly changed ( P = 0.029). In patients, the mean SSR latency was significantly prolonged compared with controls in both upper limb ( P = 0.001) and lower limb ( P = 0.000). SSR abnormalities were strongly related to sensory conduction abnormalities as detected by conventional techniques ( r = 0.39, P = 0.004). Our results showed that SSR does not seem to add to the diagnostic sensitivity of conventional techniques in chemotherapy‐induced neuropathy. However, its role in the disclosure of small fibers neuropathy abnormalities is worth considering. Further studies are warranted to address this important issue.

We describe a case of catheter-related bloodstream infection, in a patient with colon cancer, caused by a methicillin-sensitive Staphylococcus aureus strain, nontypeable by pulsed field gel electrophoresis of SmaI macrorestriction fragment analysis, belonging to ST398. The patient recovered after daptomycin therapy. This is the first report that documents the emergence of ST398 in Greece.

Recent progress with BRAF and immune checkpoint inhibitors has dramatically changed the treatment landscape of metastatic melanoma (MM). The limited duration of responses to new agents, however, justifies the, still important, role of chemotherapy in the management of MM. This study prospectively explored biomarkers to first-line temozolomide-based chemotherapy.Tumor samples from patients with advanced MM who received first-line therapy with the PVT combination (cisplatin-vinblastine-temozolomide), i.e. cisplatin (CDDP) 30 mg/m2 (days 1-3) i.v., vinblastine (CVT) 2 mg/m2 (days 1-3) i.v., temozolomide (TMZ) 150 mg/m2 (days 1-5) orally, every 21 days, were collected. Biomarkers (MGMT, ERCC1, p16), were evaluated by immunohistochemistry and BRAF mutations by PCR/sequencing.Out of 35 patients included in this clinical phase II study, 12 objective response rates were achieved (ORR; 34%) including 1 complete response CR; 9 disease stabilisations (SD; 26%), with overall clinical benefit rate (CR+PR+SD) 60%, median response duration 6 months (95% confidence interval (CI)=2-16), median PFS 4 months (95% CI=2-6), median OS 12 months (95% CI=6-25) and 1-year survival rate 52%. From 24 tumor samples evaluated for biomarkers, 13 (54%) were BRAF mutated and 11 (46%) wild-type (wt). Patients with BRAF-mutated tumors showed better response rates compared to BRAF wild-type (39% vs. 27%) and improved PFS/OS. Sub-analyses, according to BRAF status, did not reveal any significant correlations with excision repair cross-complementation group 1 enzyme (ERCC1), however, in patients with BRAF-mutated tumors, low O6-methylguanine-DNA methyltransferase (MGMT) nuclear expression correlated with better PFS, p=0.0384.First-line PVT chemotherapy for MM is efficacious and well-tolerated. Interesting 'hypothesis-generating' results show that candidate predictive biomarkers could identify subgroups of patients, i.e. tumors with BRAF mutation and low MGMT expression, with better outcomes following TMZ-based chemotherapy, thus warranting further evaluation in larger cohorts.

Gastric cancer is the fifth most common neoplasm worldwide with high rates of mortality. Afatinib, a low molecular, irreversible potent inhibitor of ErbB trans-membrane receptor family, has shown promising results according to preclinical and phase I clinical trial data when combined with chemotherapy. We aimed at evaluating the safety and efficacy of the combination of cisplatin, 5FU with afatinib in molecularly unselected patients with advanced gastric cancer.Patients with locally advanced or metastatic gastric/gastroesophageal junction adenocarcinoma received first line combination therapy of cisplatin, 5FU and afatinib every 21 days, followed by afatinib maintenance monotherapy. The primary endpoint was the Objective Response Rate (ORR); secondary endpoints included Overall Survival (OS), Progression Free Survival (PFS) and the safety profile. Unplanned exploratory analysis of HER2 and tumor mutational profile was performed.Among 55 patients (ITT population) enrolled, 19 (34.5%) achieved an objective tumor response; stable disease was observed in 16 patients (29.1%) and progressive disease in 10 patients (18.2%). The ORR in the per protocol population (PP) was 42.9%. Within a median follow-up of 56 months, the median PFS and OS in the ITT population was 5.0 and 8.7 months, respectively. Seven of the 47 HER2 informative cases carried HER2 positive tumors while TP53, BRCA2 and SMAD4 were the most frequently mutated genes. The most common toxicities were neutrophil count and white blood cell decrease occurring in 56.4% of patients, followed by anemia (50.9%), hyperglycemia (40%), and diarrhea (38.2%).The combination of cisplatin/5FU with afatinib did not surpass the benchmarks of efficacy of the contemporary therapeutic regimens that are being applied for the treatment of patients with advanced gastric cancer. However, the observed efficacy and the improved safety profile support that our administration schedule may be further investigated to overcome toxicity problems when integrating afatinib to cytotoxic chemotherapy.NCT01743365.

A randomized phase II trial was conducted to test whether the addition of gemcitabine to weekly docetaxel could improve the objective response rate and survival outcomes as second-line chemotherapy in patients with metastatic breast cancer who have failed a paclitaxel-containing regimen.Patients were randomized to receive either weekly docetaxel 40 mg/m(2) (group A, n = 34) or the combination of weekly docetaxel 35 mg/m(2) with gemcitabine 600 mg/m(2) (group B, n = 41). Three consecutive weekly infusions followed by a 1-week rest period represented 1 chemotherapy cycle.The objective response rate was 18% and 27.5% in group A and B, respectively (p = 0.413). No statistically significant differences were demonstrated in terms of median overall survival and time to disease progression. The rate and grade 3 and 4 neutropenia were higher in group B (23 vs. 3%).The weekly administration of docetaxel and gemcitabine did not result in superior clinical outcomes over weekly docetaxel.

This is a retrospective analysis of 150 patients with advanced non-small cell lung cancer who had failed prior treatment or were unfit for chemotherapy and were treated with oral gefitinib (‘Iressa’, ZD1839; AstraZeneca) 250 mg/day. Thirty-two patients who received gefitinib for 3 weeks or less were not included in the analysis. For the remaining 118 evaluable patients, the mean age was 63.1 years; most patients had received prior chemotherapy (97.5%), Eastern Cooperative Oncology Group performance status scores 0–2 (97.4%) and stage IV disease (64.4%). The majority were symptomatic (84.6%). Disease control was observed in 30 patients (25.4%), of whom five had a partial response and 25 had stable disease; 18 (15.3%) were not evaluable. Median duration of treatment was 29.9 weeks in responding patients and 11.5 in patients with progressive disease (p<0.0001). Median overall survival was 7.3 months (15.2 months for disease control) and median progression-free survival was 3.2 months. Gefitinib was well tolerated, with grade 3/4 skin rash and diarrhea seen in 2.5 and 4.2% of patients, respectively. Clinical benefit was evaluated using questionnaires before and following treatment with gefitinib. In 82 patients with completed questionnaires, evaluation revealed symptom improvement in 40.1% and improvement in general feeling in 31.4%. Epidermal growth factor receptor (EGFR) analysis found that efficacy did not correlate with tumor EGFR overexpression. Therefore, in this retrospective analysis, gefitinib treatment provided disease control in 25% of patients who derived significant palliative benefit.

In the event of malignancy the skeleton is one of the most commonly affected organs. Metastatic bone disease is associated with significant morbidity and severe complications and has become an increasingly important quality of life issue. The four main treatment modalities that are currently used for the management of bone metastases are medical treatment (including chemotherapy, bisphosphonates, and hormone therapy), radiotherapy, radiopharmaceuticals and surgery. In most cases the above treatments are either used sequentially or con-comitantly, depending on the extent and location of metastases, associated symptoms, performance status and prognosis of patients. Combination chemotherapy has shown to be an effective treatment for the overall management of patients with bone metastases, especially for patients with metastatic breast, prostate and small cell lung cancer. The therapeutic outcome and response rates are though limited in chemotherapy-resistant tumors such as non small cell lung cancer and melanoma.

Abstract In an attempt to develop more effective chemotherapy regimens in advanced nonsmall cell lung cancer (NSCLC), we evaluated docetaxel‐ifosfamide‐cisplatin (DIP) based on our previous experience with paclitaxel‐ifosfamide‐cisplatin. Patients with advanced NSCLC (stages III‐IV), WHO‐PS≤2, no prior chemotherapy and unimpaired hematopoietic and organ function were eligible. Chemotherapy was administered in successive dose levels (DLs) and included docetaxel (80–100 mg/m 2 day 1), ifosfamide (4–5 g/m 2 ) and cisplatin (80–100 mg/m 2 ), both divided over days 1 and 2 every 21 days. G‐CSF (lenograstin) was administered from days 4–13. Fifty‐five patients were accrued (phase I: 15; phase II: 40) and all are evaluable for response and toxicity: median age = 58 (40–72); PS = 1 (0–2); gender = 48 males, 7 females; stages IIIA = 8, IIIB = 19, IV = 28; and histologies were adenocarcinoma (29), squamous (20), large cell (6). Metastatic sites at diagnosis included lymph nodes (33), bone (8), liver (6), brain (6), lung nodules (9), adrenals (7) and soft tissue (1). The dose‐limiting toxicity (DLT) was reached at DL4 (Docetaxel: 100 mg/m 2 ‐Ifosfamide: 5 g/m 2 ‐Cisplatin: 100 mg/m 2 ) consisting of 2 cases of febrile neutropenia (FN), and DL3 (Docetaxel: 100 mg/m 2 ‐Ifosfamide: 5 g/m 2 ‐Cisplatin: 80 mg/m 2 ) was considered as the maximum tolerated dose (MTD) and recommended for further phase II testing. Among evaluable patients in phase II, 31/46 (67%; CI = 54–81%) responded; 4 were complete responses, 27 partial responses, 12 with stable disease and 3 with progressive disease. The median response duration was 7 months (2–21+), median time to progression (TTP) 8 months (1–23+) and median overall survival (OS) 13 months (2–23+). The 1‐year survival was 57%. Grade (Gr) 3/4 toxicities included neutropenia 39/46 with 27 developing Gr4 (≤7 days) and 20% FN managed successfully with broad‐spectrum antibiotics, thrombocytopenia Gr3 3/46‐Gr4 1/46, no Gr3 neuropathy, Gr1‐2 CNS toxicity in 12, no renal toxicity, 15 Gr2 myalgias, 17 Gr2 diarrhea and 10 Gr3 vomiting. In the present phase I‐II study, DIP appears highly active and tolerable in advanced NSCLC in the outpatient setting. Randomized comparisons to current standard 2‐drug regimens will be warranted. © 2001 Wiley‐Liss, Inc.

Single photon emission tomography/computed tomography (SPET/CT) is usually recommended after ambiguous whole body bone scan (WBS) findings. We investigated the value of routine 2-field ("near" whole-body) SPET/CT application in breast cancer (BC) patients.In this prospective study planar WBS and 2-field SPET/CT was performed in 257 consecutive BC patients referred for a bone scan. Whole body scan and SPET/CT were interpreted separately. Additional imaging studies and clinical follow-up for 30±24 months elucidated uncertain findings.Bone metastases were confirmed in 65 patients (25.3%). Sensitivity, specificity, accuracy, positive and negative predictive value per-patient was 63.1%, 81.3%, 76.7%, 53.2% and 86.7% for WBS and 96.9%, 87.5%, 89.9%, 72.4% and 98,8% for SPET/CT; differences were statistically significant except for specificity. Respective values of sensitivity per-lesion were 47.6% and 98.9% (P<0.001). Eleven percent of true positive findings were noticed only in the low-dose CT images, while 7% only in SPET. Single photon emission tomography/CT exhibited higher specificity than WBS in the spine (94.8% vs. 88.7%, P=0.04). Whole body scan interpretation changed after SPET/CT in 74 (28.8%) patients. Thirty-two patients with positive/suspicious WBS turned to be metastases-free after the interpretation of SPET/CT while 42 with unremarkable WBS turned to be positive/suspicious. Of these cases, metastases were confirmed in one with negative and 23 with positive/suspicious SPET/CT. The SPET/CT results prompted treatment plan changes in 23 cases (8.9%).Whole-body bone SPET/CT scan outperformed WBS in terms of sensitivity, accuracy, positive and negative predictive value and impacted on patient management. Therefore, its use is recommended as a routine procedure in BC patients, even after a negative WBS.

Germline mutations in the BRCA1 and BRCA2 genes contribute to approximately 18% of hereditary ovarian cancers conferring an estimated lifetime risk from 15% to 50%.A variable incidence of mutations has been reported for these genes in ovarian cancer cases from different populations.In Greece, six mutations in BRCA1 account for 63% of all mutations detected in both BRCA1 and BRCA2 genes.This study aimed to determine the prevalence of BRCA1 mutations in a Greek cohort of 106 familial ovarian cancer patients that had strong family history or metachronous breast cancer and 592 sporadic ovarian cancer cases.All 698 patients were screened for the six recurrent Greek mutations (including founder mutations c.5266dupC, p.G1738R and the three large deletions of exon 20, exons 23-24 and exon 24).In familial cases, the BRCA1 gene was consequently screened for exons 5,11,12,20,21,22,23,24.A deleterious BRCA1 mutation was found in 43/106 (40.6%) of familial cancer cases and in 27/592 (4.6%) of sporadic cases.The variant of unknown clinical significance p.V1833M was identified in 9/698 patients (1.3%).The majority of BRCA1 carriers (71.2%) presented a high-grade serous phenotype.Identifying a mutation in the BRCA1 gene among breast and/or ovarian cancer families is important, as it enables carriers to take preventive measures.All ovarian cancer patients with a serous phenotype should be considered for genetic testing.Further studies are warranted to determine the prevalence of mutations in the rest of the BRCA1 gene, in the BRCA2 gene, and other novel predisposing genes for breast and ovarian cancer.

3541 Background: The purpose of the trial was to compare two standard chemotherapy regimens combined with bevacizumab (Bev) in patients with metastatic colorectal cancer. Methods: Patients previously untreated for metastatic disease were randomized in: Arm A (irinotecan 240 mg/m2 day 1, capecitabine 1,000 mg/m2 days 1-14 and Bev 7.5 mg/kg day 1, every 3 weeks; XELIRI-Bev) and Arm B (irinotecan 180 mg/m2 day 1, leucovorin 200 mg/m2 day 1, fluorouracil 400 mg/m2 bolus on day 1 followed by a fluorouracil 2,400 mg/m2 46 hours infusion, and Bev 5 mg/kg day 1, every 2 weeks; FOLFIRI-Bev). Primary end-point was progression-free survival (PFS). Secondary end-points were overall survival (OS), objective response and toxicity. Results: From January 2006 to January 2008, 285 eligible patients were enrolled (143 in arm A, 142 in arm B). Median age was 66 years (range 28-84), 171 patients (60%) were males and 186 (65%) had PS (ECOG) = 0. The liver was involved in 190 patients (67%), while 153 (54%) had only one organ involved. Fifty-five patients (38%, CR = 4%, PR = 34%) in arm A and 57 (40%, CR = 3%, PR = 37%) in arm B had responded (p = 0.81), whereas 28 patients (20%) in arm A and 40 (28%) in arm B had stable disease. After a median follow-up of 28.7 months (0.2-43.8), 86 vs 102 disease progressions, and 81 vs 75 deaths had occurred in arms A and B, respectively. Median PFS was 14.6 (95% CI = 12.4-16.7) and 15.8 (95% CI = 13.4-18.2) months (p = 0.48), while median OS was 20.0 (95% CI = 16.7-23.3) and 26.2 (95% CI = 22.0-30.4) months (p = 0.14), for arms A and B, respectively. Most frequent grade 3-4 toxicities (arm A vs. arm B) were neutropenia (12% vs. 22%, p = 0.048), leucopenia (6% vs. 4%), diarrhea (18% vs. 11%), metabolic disorders (8% vs. 18%, p = 0.028), and vomiting (7% vs. 0%, p = 0.014). Conclusions: This trial did not show significant differences in efficacy between XELIRI-Bev and FOLFIRI-Bev in patients with metastatic colorectal cancer treated in the first-line setting. However, the toxicity profile was different. Translational research on angiogenesis factors is ongoing. No significant financial relationships to disclose.

OBJECT The aim of the study was to investigate whether there are seasonal differences in the occurrence of carcinomatous meningitis (CM), with a greater prevalence of the disease in months with higher temperatures. METHODS The authors searched the records of all patients with a diagnosis of CM from 1998 until 2013 at the University Hospital of Patras, Greece. The date of hospitalization was extracted for each patient. The cases were divided into 2 categories depending on the time of CM diagnosis. Based on the official data regarding the annual temperature distribution in this region, the authors divided the patients into 2 groups. The first group consisted of cases diagnosed with CM from October 15 to April 15 (cold climate and shorter daytime duration), whereas the second group comprised patients diagnosed between April 15 and October 15 (warm climate and longer daytime duration). RESULTS Overall, 44 confirmed cases of CM were found. The most common type of malignancy associated with the development of CM was breast cancer (27 patients), while the second most common tumor was lung carcinoma (11 patients). The median interval between the time of initial cancer diagnosis and CM was 4.5 years. Thirty-one patients were diagnosed with CM during the period between April 15 and October 15, while the remaining 13 patients developed CM between October 15 and April 15, a significant difference (p = 0.01). CONCLUSIONS Significantly more patients developed CM during the warm season of the year. To the authors' knowledge, this is the first study to provide evidence for the potential seasonal variability in CM incidence. However, these results should be validated prospectively in larger cohorts.

A phase I pharmacokinetics and dose-finding study and a phase II study of the combination of pegylated liposomal doxorubicin HCl (PLD) and paclitaxel were conducted in patients with recurrent or metastatic head and neck cancer (HNC). Sixty patients with recurrent or metastatic disease were enrolled in the study: 11 patients in the phase I study and 49 patients in the phase II study. In the phase I study, the initial dose level of PLD was 35 mg/m as a 1-h infusion with escalating increments of 5 mg/m until the maximum tolerated dose (MTD) was reached. A fixed dose of paclitaxel (175 mg/m) was administered as a 3-h infusion. The combination was administered every 28 days. Pharmacokinetic studies performed on 10 patients indicated that the sequence of drug administration did not cause clinically significant modifications in the pharmacokinetics of either drug. The MTD for PLD was 45 mg/m (dose level 3) and the dose-limiting toxicity was febrile neutropenia, occurring in three of five patients. The phase II dose of PLD was 40 mg/m (dose level 2) and a total of 214 cycles were delivered. Grade 3 or 4 neutropenia was observed in 26% patients and febrile neutropenia occurred in 16% of patients. Grade 3 palmar-plantar erythrodysesthesia (PPE) was recorded in only one patient. The overall response rate was 28% for patients with non-nasopharyngeal tumors [95% confidence interval (CI) 15-45%] and 28.6% for the study population (95% CI 17-43%). The median survival for the study population was 9.7 months; 1-year survival was 38%. We conclude that the recommended dose for the combination of PLD and paclitaxel is 40 and 175 mg/m every 28 days, without granulocyte colony stimulating factor support. The combination of paclitaxel with PLD demonstrated activity in recurrent or metastatic HNC, a favorable toxicity profile and relative ease of administration.

Objectives Adjuvant carboplatin is used as adjuvant therapy in Stage I testicular seminoma. Although cure is the rule, relapses still occur, especially in high-risk populations. We report the results of a risk-adapted strategy by the Hellenic Cooperative Oncology Group. Methods From 1996 to 2003, 64 patients with Stage I seminoma and one of two risk factors (maximal tumor diameter greater than 4 cm and/or age younger than 34 years) were prospectively included in a protocol of adjuvant chemotherapy. Treatment consisted of two 3-week courses of etoposide 120 mg/m2 and cisplatin 40 mg/m2 for three consecutive days with granulocyte colony-stimulating factor support. Results Of the 64 patients, 43 (67%) were younger than 34 years and 55 (86%) had a tumor diameter greater than 4 cm. Neutropenia and nausea and vomiting were the most frequent grade 3 or 4 toxicities (16.5% and 9.5%, respectively), apart from alopecia. After a median follow-up of 60 months (range 7 to 118), no disease relapses have occurred. A metachronous testicular carcinoma has been reported. One patient died of causes unrelated to his disease. Conclusions The results of our study have shown that two cycles of etoposide and cisplatin is an effective and safe form of adjuvant therapy for Stage I testicular seminoma. Risk factors can be used to identify patients who could benefit from etoposide and cisplatin treatment. Adjuvant carboplatin is used as adjuvant therapy in Stage I testicular seminoma. Although cure is the rule, relapses still occur, especially in high-risk populations. We report the results of a risk-adapted strategy by the Hellenic Cooperative Oncology Group. From 1996 to 2003, 64 patients with Stage I seminoma and one of two risk factors (maximal tumor diameter greater than 4 cm and/or age younger than 34 years) were prospectively included in a protocol of adjuvant chemotherapy. Treatment consisted of two 3-week courses of etoposide 120 mg/m2 and cisplatin 40 mg/m2 for three consecutive days with granulocyte colony-stimulating factor support. Of the 64 patients, 43 (67%) were younger than 34 years and 55 (86%) had a tumor diameter greater than 4 cm. Neutropenia and nausea and vomiting were the most frequent grade 3 or 4 toxicities (16.5% and 9.5%, respectively), apart from alopecia. After a median follow-up of 60 months (range 7 to 118), no disease relapses have occurred. A metachronous testicular carcinoma has been reported. One patient died of causes unrelated to his disease. The results of our study have shown that two cycles of etoposide and cisplatin is an effective and safe form of adjuvant therapy for Stage I testicular seminoma. Risk factors can be used to identify patients who could benefit from etoposide and cisplatin treatment.

Immune checkpoint inhibitors (ICI) are anti-cancer drugs that act by enhancing anti-tumour immunity. Due to their mechanism of action, they have been associated with immune related adverse events (Ir-AE), including musculoskeletal manifestations.To assess a) the prevalence, clinical and imaging (MRI) characteristics of ICI-induced musculoskeletal immune related adverse events (ir-AE) in a prospective manner, b) the potential association of musculoskeletal ir-AE with oncologic response and changes in the immune system at the level of soluble molecules (cytokines) as well as T/B cell subpopulations.This a multicentre prospective study. We plan to recruit all patients who are going to start treatment with ICI from October 2019 until October 2020 in all collaborating Oncology Departments. This study is consisted of a clinical and a laboratory arm.The study is currently recruiting patients.We anticipate that this study will provide useful data regarding the clinical characteristics of ICI-induced musculoskeletal manifestations as well as potential predictive biomarkers.

Gemcitabine and mitoxantrone have both shown significant antitumor activity in patients with breast cancer. The aim of this study was to evaluate the efficacy and safety of this combination as second or third-line treatment in patients with metastatic breast cancer (MBC).Forty-six previously treated patients with MBC were enrolled from June 2000 to November 2002. Mean age was 56 years and ECOG performance status was ≤2. All patients received mitoxantrone 10 mg/m2, D8 and gemcitabine 1000 mg/m2, D1+8 every 21 days for 6 cycles.There were no complete responders. Objective response was observed in 12 patients (26%), 15 (33%) patients had stable disease, 15 (33%) had progressive disease and 4 (9%) were non-evaluable. At median follow-up of 27.8 months, overall survival was 13.3 months (range 0.6-33.8+) and the median time to disease progression (TTP) was 4.4 months (range 0.2-33.8). Toxicities (grade 3-4) were as follows: leukopenia 18 (39%), neutropenia 19 (41%), thrombocytopenia 4 (8.5%), anemia 6 (13%) and alopecia 1 (2%). Febrile neutropenia was recorded in 2 (4%) patients. There were no treatment related deaths.The authors conclude that the combination of mitoxantrone and gemcitabine is an effective regimen in pretreated patients with metastatic breast cancer. Toxicity was manageable.

Purpose Implantable venous access ports are widely used in patients receiving chemotherapy, but there is still scarce evidence about any patient-reported outcome measures. This prospective randomized controlled trial examined the impact on patients’ quality-of-life following the placement of an implantable port device for long-term chemotherapy treatment. Method A total of 120 chemotherapy naïve adult outpatients scheduled to receive chemotherapy (duration ≥12 weeks) for solid tissue tumors in a single academic oncology unit were randomly allocated (n = 60 in each arm) between radiologically guided insertion of an implantable venous access port (PORT arm) or standard repeated peripheral venous access (Control arm). Health-related quality-of-life scores (HRQoL) were assessed with the EQ-5D-5L and the oncology-specific EORTC QLQ-C30 (version 3.0) questionnaires at baseline, 3- and 6-months post randomization. Non-parametric tests were applied and differences between medians (Δ) are reported because of skewed-left HRQoL data. Results Baseline clinical and demographic characteristics were well balanced between the two groups. There were no complications during insertion and no infection or device failure in the PORT subjects through the 6-month follow-up. The functional and symptom scales of the EORTC QLQ-C30 questionnaire were similar between both study arms at all time intervals. The EORTC QLQ-C30 global health status was significantly improved in the PORT subjects both at 3 months (Δ: 8.3 out of 100; P = 0.04) and 6 months follow-up (Δ: 16.7 out of 100; P = 0.003). Changes in EQ-5D-5L scores were significantly improved at 6 months in the PORT arm compared to control (Δ: 0.074 out of 1; P = 0.01). Conclusions Implantable venous access ports may confer significantly improved patient-reported quality-of-life benefits in patients receiving chemotherapy for solid tissue tumors.

Epithelial ovarian carcinomas are successfully treated but seldom cured with standard platinum-based chemotherapy regimens. Investigation continues on the role of high-dose chemotherapy as part of salvage, consolidation and primary induction treatment strategies. Currently, the majority of available clinical studies suggest that modest increases in the dose of platinum in primary induction therapy does not translate into increased survival and comes at the cost of increased toxicity. Interest continues in the use of very high-dose chemotherapy regimens typically with peripheral blood stem cell or bone marrow transplantation. Several series have demonstrated that this approach can provide prolonged disease-free survival in a subset of carefully selected patients with low-volume chemotherapy-sensitive disease. The appropriate application of this expensive and potentially toxic treatment to women with ovarian cancer requires further clinical investigation.

Background: This study reports the long-term follow-up of patients with metastatic colorectal cancer (CRC) participating in a randomised phase II study that compared the efficacy and toxicity of the combination of irinotecan (IRI), fluorouracil (FU) with leucovorin (LV) (arm A) versus sequential chemotherapy with IRI plus FU/LV followed by oxaliplatin (OXA) plus FU/LV (arm B) as first line therapy. Materials and Methods: Intent-to-treat analysis was performed on 417 patients (211 in arm A and 206 in arm B). Treatment schedules of weekly IRI 80 mg/m 2 or OXA 45 mg/m 2 plus LV 200 mg/m 2 immediately followed by intravenous bolus FU 450 mg/m 2 for 6 weeks were followed by a 2-week rest period. Treatment continued for 4 cycles. Patients in arm A were treated with IRI/FU/LV for 4 cycles, while patients in arm B were initially treated with IRI/FU/LV for 2 cycles followed by sequential administration of 2 cycles of OXA/FU/LV. Results: No significant difference emerged in overall response rate or overall survival. There was a difference in progression-free survival (median, 7.3 versus 8.2 months, p=0.040) in favour of arm B. Toxicity profiles were similar in both arms. Conclusion: IRI/FU/LV and IRI/FU/LV followed by OXA/FU/LV showed comparable activity with a manageable toxicity profile. Colorectal cancer (CRC) is a worldwide public health problem, accounting for nearly 800,000 new cases diagnosed each year and approximately 500,000 deaths (1). Significant advances have been made in the management options for patients with metastatic disease and a median survival of 21- 24 months is now frequently reported. Over the past 10 years, three new chemotherapeutic agents have been approved for metastatic CRC. These compounds

829 Background: Gemcitabine and mitoxantrone have both been demonstrated significant antitumor activity in patients with breast cancer. The aim of the study was to evaluate the efficacy and safety of the combination as second or third line treatment in patients with advanced breast cancer (ABC). Methods: Fifty-six previously treated patients with ABC were enrolled from June 2000 to November 2002 and 46 were eligible. Mean age was 56 years (range 35–72) and ECOG performance status was <3. Sites of metastasis were as follows: liver 56%, bones 48%, lungs 46%, lymph nodes 17%. All patients received mitoxantrone 10mg/m2, D1 and gemcitabine 1000mg/m2, D1+8 every 21 days for 6 cycles. The relative dose intensity of mitoxantrone and gemcitabine was 0.76 and 0.77, respectively. A total of 211 cycles were delivered. Results: All patients were analyzed for toxicity for response. There were no complete responders. The objective response rate was 24% (95% confidence interval [CI] 12.6–38.8), 15 (33%) patients had stable disease, 15 (33%) had progressive disease and 4 (9%) were nonevaluable. At median follow up of 27.8 months overall survival was 13.3 months (range 0.6–33.8+) and the median time to disease progression was 4.4 months (range 0.2–33.8). Toxicities (grade III-IV) were as follows: leukopenia 18 (39%), neutropenia 19 (41%), thrombocytopenia 4 (8,5%), anemia 6 (13%) and alopecia 1 (2%). Febrile neutropenia was recorded in 2 (4%) patients. There were no treatment-related deaths. Conclusions: The combination of mitoxantrone and gemcitabine is an effective and well-tolerated regimen in pretreated patients with advanced breast cancer. No significant financial relationships to disclose.

Introduction: Expression of Transcribed Ultra Conserved Regions (Transcribed Ultra Conserved Regions, T-UCRs) is often deregulated in many types of cancer, including colorectal cancer (CRC). Our previous results showed that T-UCRs Uc160 and Uc346 are methylated in CRC. Additionally, their tumor methylation is associated with time to disease progression (TTP) and appears to be a promising biomarker for CRC. However, their role in CRC progression has not been elucidated to date. Methods: Aim of the study was to investigate the role of Uc160 and Uc346 in proliferation, motility and migration in colon cancer cells. For that purpose, Uc160 and Uc346 were cloned into plasmids and three colon cancer cell lines (HT-29, Caco-2 and DLD-1) were transiently transfected. After overexpression of Uc160 and Uc346, proliferation (ΜΤΤ assay), motility (scratch wound healing assay) and migration (transwell migration assay) rates were evaluated. Results: Proliferation rates, 48h after overexpression, were higher in the transfected cell in all cell lines, compared with the control cells (mock transfected). The most significant differences in proliferation rates were noticed for Uc160 overexpression in Caco-2 (p = 0.008) and Uc346 overexpression in DLD-1 cells (p = 0.033). Similar results were observed in motility assay, with cells overexpressing Uc160 or Uc346 having higher motility rates compared to control cells in all cell lines. More specifically, most significant differences in motility rates were observed in HT-29 and DLD-1 cells overexpressing Uc160 or Uc346 (p = 0.017, p = 0.041 and p = 0.023, p = 0.004 respectively). Further analysis of DLD-1 cells migration confirmed the above results, with higher number of Uc160 or Uc346 overexpressing cells migrating compared to the control cells (p = 0.005 for both T-UCRs). Conclusion: T-UCRs Uc160 and Uc346 appear to affect the proliferation, motility and migration rates of colon cancer cells, implicating a complex role in CRC progression.

Background: We evaluated the association between pathogenic mutations and overall survival (OS) in patients with cancer referred to Hellenic Cooperative Oncology Group-affiliated Departments.Patients and methods: Patients referred from 12/1980 to 1/2017 had molecular testing (for research) of archival tumor tissue collected at the time of first diagnosis (non-metastatic, 81%; metastatic, 19%).Tumor-specific gene panels (16-101 genes) were used to identify pathogenic mutations in clinically relevant genes.NGS genotyping was performed at the Laboratory of Molecular Oncology, Aristotle University of Thessaloniki.Annotation of mutations was performed at MD Anderson Cancer Center.Results: We analyzed 3,084 patients (median age, 57 years; men, 22%) with sequencing data.Overall, 1,775 (58% of 3,084) patients had pathogenic mutations.The median follow-up was 7.52 years (95% CI, 7.39-7.61).In patients with nonmetastatic tumors, after stratification by tumor type, increasing age, higher grade, and histology other than adenocarcinoma were associated with shorter OS.OS was also shorter in patients with pathogenic TP53 (HR=1.36;p<0.001),MLL3 (HR=1.64;p=0.005), and BRCA1 (HR=1.46;p=0.047) mutations compared to wild-type genes.In multivariate analyses, independent prognostic factors predicting shorter OS were pathogenic mutations in TP53 (HR=1.37,p=0.002) and MLL3 (HR=1.50,p=0.027); increasing age (HR=1.02,p<0.001); and increasing grade (HR=1.46,p<0.001).In patients with metastatic cancer, older age and higher grade were associated with shorter OS and maintained their independent prognostic significance (increasing age, HR=1.03, p<0.001 and higher grade, HR=1.73, p<0.001).Conclusions: Analysis of molecular data reveals prognostic biomarkers, regardless of tissue or organ of origin to improve patient management.www.oncotarget.com

The Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) family of transcription factors plays an important role in immune responses and cancer development and progression. We have focused on NF-κB2 and RELB of the alternative pathway of NF-κB, which remains largely underexplored in colorectal cancer (CRC). We found that NF-κB2 and RELB protein levels were upregulated in tumour and surrounding stromal tissue compared to distant non-neoplastic tissue (NN) and associated stroma (p<0.001 in all associations). Moreover, low RELB protein expression was associated with decreased overall survival (p = 0.032). Lower RELB gene expression levels were observed in tumour compared to NN tissue (p = 0.003) and were associated with shorter time to progression (TTP) (p = 0.025). NF-κB2 gene expression levels were similar in tumour and NN tissue, but higher tumour levels were prognostic for improved survival (p = 0.038) and TTP (p<0.001). We also assessed the significance of two NF-κB2 genetic polymorphisms, rs12769316 and rs7897947. Both polymorphisms were associated with lymph node infiltration (p = 0.045 and p = 0.009, respectively). In addition, rs12769316 AA homozygotes relapsed less often compared to G allele carriers (p = 0.029). Moreover, rs7897947 allele frequencies differed significantly between CRC patients and healthy controls (p<0.001) and the minor allele (G) was associated with reduced risk for developing CRC (p<0.001, OR: 0.527, 95% CI: 0.387–0.717). In conclusion, the alternative NF-κB pathway appears deregulated in CRC. Moreover, NF-κB2 and RELB expression levels seem to be significant for the clinical outcome of CRC patients and rs7897947 appears to be a risk factor for CRC development.

Colorectal cancer remains a major cause of cancer mortality in the Western world both in men and women. In this manuscript a concise overview and recommendations on adjuvant chemotherapy in colon cancer are presented. An executive team from the Hellenic Society of Medical Oncology was assigned to develop a consensus statement and guidelines on the adjuvant treatment of colon cancer. Fourteen statements on adjuvant treatment were subjected to the Delphi methodology. Voting experts were 68. All statements achieved a rate of consensus above than 80% (>87%) and none revised and entered to a second round of voting. Three and 8 of them achieved a 100 and an over than 90% consensus, respectively. These statements describe evaluations of therapies in clinical practice. They could be considered as general guidelines based on best available evidence for assistance in treatment decision-making. Furthermore, they serve to identify questions and targets for further research and the settings in which investigational therapy could be considered.

Expression of Transcribed Ultra Conserved Regions (T-UCRs) is often dysregulated in various types of cancer. Regulation of T-UCR expression includes epigenetic mechanisms, and in particular CpG island methylation. Three T-UCRs (160, 283 and 346) have been found to be methylated in colon adenocarcinomas. The present study assesses the use of the T-UCR methylation status in circulating DNA as a diagnostic marker for colorectal cancer (CRC). Expression and methylation levels of T-UCRs 160, 283 and 346 were assessed in neoplastic and paired normal colonic fresh frozen tissue specimens from 75 CRC patients, as well as in 5 fresh frozen adenoma tissue specimens. Methylation status of the three T-UCRs was also determined in plasma from 161 patients (56 CRC patients, 55 adenoma patients, 40 healthy subjects and 10 patients with colon inflammation or diverticulosis). Expression levels of all three T-UCRs were lower in neoplastic tissues, compared to normal adjacent colonic tissues, but only in T-UCR 160 the difference was statistically significant (p < 0.001). Methylation levels of 160, 283 and 346 were higher in colorectal cancer tissues compared to normal adjacent tissues (p < 0.001, p = 0.029 and p = 0.005 respectively). Notably, methylation levels of 160 and 346 in adenomas were higher than those in normal tissues but lower than those in cancer tissues. Methylation status of 160 in plasma differed significantly among the four different groups of patients (p = 0.024) and the difference increased when we compared methylation status in colorectal adenoma or adenocarcinoma patients with healthy subjects or patients with inflammation or diverticulosis (p = 0.007). When methylation status was used to predict if a subject has colorectal adenocarcinoma, specificity and sensitivity were 85% and 30% respectively. Methylation of T-UCR 160 in plasma has great specificity for CRC but low sensitivity. Alteration of the methodological approaches to improve the sensitivity could result in a promising non-invasive screening method for CRC.

e21096 Background: Ιmmune checkpoint inhibitors (ICIs) have tremendously changed the daily clinical practice on the treatment of advanced non-small cell lung cancer (aNSCLC). However, clinical useful biomarkers remain an unmet need. Recently, a new score, Patras Immunotherapy Score (PIOS), has been proposed by our group proving its prognostic value in aNSCLC patients treated with ICIs monotherapy. The objective of the current study was to assess the clinical significance of PIOS formula in aNSCLC patients treated with combination of immunotherapy with chemotherapy. Methods: PIOS is a baseline formula derived by combining the following non-interventional clinical parameters, Performance Status (PS), Body Mass Index (BMI), age and Line Of Treatment (LOT) and it is calculated as PIOS = (PS×BMI)/(LOT×AGE). In the current study, 159 aNSCLC patients, treated with combination of immunotherapy with chemotherapy, were retrospectively selected, blindly to the clinical outcome, and enrolled. In addition, a second subcohort with 444 aNSCLC patients, who had been treated with chemotherapy alone, were also retrospectively included. The primary endpoint of this study was to investigate the prognostic value of PIOS in terms of progression free survival (PFS) and overall survival (OS). Results: Patients with higher PIOS score had longer PFS compared to patients with lower PIOS score (ΗR 0.575, 95% CI 0.364-0.908, p= 0.016), while multivariate analysis for PFS, adjusted for PD-L1, confirmed the clinical value of PIOS score (HR 0.561, 95% CI 0.352-0.893, p= 0.015). Moreover, PIOS score was also associated with prognosis ( p= 0.003). The median OS for the favorable group was 1067 days compared to 528 days for the unfavorable group with low PIOS score (HR 0.487, 95% CI 0.302-0.787, p&lt; 0.001) at univariate analysis. This association remained statistically significant (HR 0.468, 95% CI 0.286-0.764, p= 0.002) after adjusting for PD-L1 expression. Specificity of PIOS formula was also confirmed in the second cohort (n = 444) of patients with metastatic disease who had been treated with chemotherapy alone, in which no prognostic significance for PIOS was observed. Conclusions: This study for the first time documents the prognostic significance of PIOS model in aNSCLC patients treated with immunotherapy/chemotherapy combination and provides adequate evidence regarding the specificity of this association, since no similar finding was observed in the patients treated with chemotherapy alone.

A 69-year-old woman presented in October 1998 with abdominal pain and distension. On physical examination, ascites and tenderness on palpating the lower abdominal area were found. An abdominal computed tomography (CT) scan revealed a 4.5 cm mass in the left ovary with multiple peritoneal implants and ascites. The serum tumor marker CA 125 was 190 U/ml (normal, <32), whereas thyroid hormones were within normal limits: thyroid-stimulating hormone (TSH) 5.1 U/ml, thyroxine 7.2 U/ml, tri-iodothyronine 1.2 U/ml.She underwent a staging laparotomy and abdominal hysterectomy with bilateral salpingo-ophorectomy and omentectomy stage IIIC disease was detected. Histology was consistent with serous cystadenocarcinoma grade 1–2. She received six cycles of chemotherapy with paclitaxel and carboplatin or cisplatin (alternate cycles). Toxicity was limited to grade 1 peripheral neuropathy with mild numbness in a glove-and-stocking distribution. No alopecia was evident at this point. At the end of chemotherapy, an abdominal CT scan showed complete radiological remission and serum CA 125 within normal limits.One month later, she developed clinical signs of hypothyroidism, and TSH was 90 U/ml. On questioning, it appeared that the patient elected on her own to discontinue thyroxine replacement at the start of chemotherapy without informing the medical team. Thyroxine replacement therapy was recommenced and 2 months later thyroid hormones were within normal limits. As soon as thyroid function was restored, alopecia grade 2 appeared, 3 months after the completion of chemotherapy. Grade 2 alopecia was present for almost 2 months, after which hair regrowth was apparent.Nine months later, the patient developed intra-abdominal relapse, and despite salvage treatment attempts, she died 3 months later from progressive disease.The current case represents a very rare, probably unique, clinical entity. A possible explanation of the delayed onset of alopecia after the completion of paclitaxel chemotherapy could be attributed to the combined effects of thyroid hormones and chemotherapy upon the biological cycle of hair. Each hair follicle continually goes through three stages: anagen (growth), catagen (involution), and telogen (rest) [1.Paus R. Cotsarelis G. The biology of hair follicles.N Engl J Med. 1999; 341: 491-497Crossref PubMed Scopus (947) Google Scholar]. Anagen is followed by catagen when hair follicles go through a highly controlled process ofinvolution. Ultimately, the hair follicle enters the telogen stage when the hair shaft matures into a club hair which is eventually shed from the follicle [1.Paus R. Cotsarelis G. The biology of hair follicles.N Engl J Med. 1999; 341: 491-497Crossref PubMed Scopus (947) Google Scholar]. The telogen stage lasts 2–3 months before the follicles re-enter the anagen stage and the cycle is repeated. At any given point, most of the hair follicles can be found in the anagen phase with only a small percentage in the telogen phase and just a few in the catagen phase (Figure 1).Hair growth is influenced by many factors, including hormones, whose mechanism of action is not fully understood [2.Paus R. Control of the hair cycle and hair diseases as cycling disorders.Curr Opin Dermatol. 1996; 3: 248-258Google Scholar, 3.Lindner G. Botchkareva V.A. Botchkareva N.V. et al.Analysis of apoptosis during hair follicle regression.Am J Pathol. 1997; 151: 1601-1617PubMed Google Scholar]. Antineoplastic drugs disrupt the rapidly proliferating bulb matrix cells during the anagen stage. As a result, hair production ceases and the hair shaft becomes narrower with subsequent breakage and loss of hair; a phenomenon called anagen effluvium [4.Cancer, cancer therapy and hair.Lancet. 1983; 2: 1177-1178PubMed Google Scholar, 5.Cline B.W. Prevention of chemotherapy-induced alopecia: a review of the literature.Cancer Nurs. 1984; 7: 221-228Crossref PubMed Google Scholar]. Telogen effluvium is the excessive shedding of hair caused by an increased proportion of follicles entering the telogen stage. Low levels of thyroxine cause telogen effluvium [2.Paus R. Control of the hair cycle and hair diseases as cycling disorders.Curr Opin Dermatol. 1996; 3: 248-258Google Scholar].In our clinical case, the patient was hypothyroid during chemotherapy with paclitaxel, due to the cessation of thyroxine replacement. As a result, most hair follicles probably entered the telogen stage (Figure 1). We hypothesize that paclitaxel could not act in the hair follicles that were in the telogen stage and thus no alopecia appeared (Figure 1). Once thyroid function was restored, it is likely that the telogen stage was completed leading to telogen effluvium, and alopecia grade 2 developed. Another factor that may contribute to the development of alopecia is the possibility of paclitaxel accumulating in the scalp and causing anagen effluvium. Since an increase in the percentage of follicles in the telogen stage leads to excessive shedding and telogen effluvium, drugs that reduce the percentage of hair follicles in this stage or prevent the evolution of hair follicles to this stage could be valuable in treating hair loss [3.Lindner G. Botchkareva V.A. Botchkareva N.V. et al.Analysis of apoptosis during hair follicle regression.Am J Pathol. 1997; 151: 1601-1617PubMed Google Scholar, 5.Cline B.W. Prevention of chemotherapy-induced alopecia: a review of the literature.Cancer Nurs. 1984; 7: 221-228Crossref PubMed Google Scholar].In conclusion, the above clinical case represents a very rareclinical phenomena that shows an interesting interaction of two different factors in the regulation of hair growth. The mechanism of action and interaction of various factors such as thyroid hormones and chemotherapeutic agents in the biological cycle of hair growth is still poorly understood. Progress in our understanding of the biology and pathophysiology of hair follicles should lead to more effective therapies for disorders of hair growth, including chemotherapy-induced alopecia. A 69-year-old woman presented in October 1998 with abdominal pain and distension. On physical examination, ascites and tenderness on palpating the lower abdominal area were found. An abdominal computed tomography (CT) scan revealed a 4.5 cm mass in the left ovary with multiple peritoneal implants and ascites. The serum tumor marker CA 125 was 190 U/ml (normal, <32), whereas thyroid hormones were within normal limits: thyroid-stimulating hormone (TSH) 5.1 U/ml, thyroxine 7.2 U/ml, tri-iodothyronine 1.2 U/ml. She underwent a staging laparotomy and abdominal hysterectomy with bilateral salpingo-ophorectomy and omentectomy stage IIIC disease was detected. Histology was consistent with serous cystadenocarcinoma grade 1–2. She received six cycles of chemotherapy with paclitaxel and carboplatin or cisplatin (alternate cycles). Toxicity was limited to grade 1 peripheral neuropathy with mild numbness in a glove-and-stocking distribution. No alopecia was evident at this point. At the end of chemotherapy, an abdominal CT scan showed complete radiological remission and serum CA 125 within normal limits. One month later, she developed clinical signs of hypothyroidism, and TSH was 90 U/ml. On questioning, it appeared that the patient elected on her own to discontinue thyroxine replacement at the start of chemotherapy without informing the medical team. Thyroxine replacement therapy was recommenced and 2 months later thyroid hormones were within normal limits. As soon as thyroid function was restored, alopecia grade 2 appeared, 3 months after the completion of chemotherapy. Grade 2 alopecia was present for almost 2 months, after which hair regrowth was apparent. Nine months later, the patient developed intra-abdominal relapse, and despite salvage treatment attempts, she died 3 months later from progressive disease. The current case represents a very rare, probably unique, clinical entity. A possible explanation of the delayed onset of alopecia after the completion of paclitaxel chemotherapy could be attributed to the combined effects of thyroid hormones and chemotherapy upon the biological cycle of hair. Each hair follicle continually goes through three stages: anagen (growth), catagen (involution), and telogen (rest) [1.Paus R. Cotsarelis G. The biology of hair follicles.N Engl J Med. 1999; 341: 491-497Crossref PubMed Scopus (947) Google Scholar]. Anagen is followed by catagen when hair follicles go through a highly controlled process ofinvolution. Ultimately, the hair follicle enters the telogen stage when the hair shaft matures into a club hair which is eventually shed from the follicle [1.Paus R. Cotsarelis G. The biology of hair follicles.N Engl J Med. 1999; 341: 491-497Crossref PubMed Scopus (947) Google Scholar]. The telogen stage lasts 2–3 months before the follicles re-enter the anagen stage and the cycle is repeated. At any given point, most of the hair follicles can be found in the anagen phase with only a small percentage in the telogen phase and just a few in the catagen phase (Figure 1). Hair growth is influenced by many factors, including hormones, whose mechanism of action is not fully understood [2.Paus R. Control of the hair cycle and hair diseases as cycling disorders.Curr Opin Dermatol. 1996; 3: 248-258Google Scholar, 3.Lindner G. Botchkareva V.A. Botchkareva N.V. et al.Analysis of apoptosis during hair follicle regression.Am J Pathol. 1997; 151: 1601-1617PubMed Google Scholar]. Antineoplastic drugs disrupt the rapidly proliferating bulb matrix cells during the anagen stage. As a result, hair production ceases and the hair shaft becomes narrower with subsequent breakage and loss of hair; a phenomenon called anagen effluvium [4.Cancer, cancer therapy and hair.Lancet. 1983; 2: 1177-1178PubMed Google Scholar, 5.Cline B.W. Prevention of chemotherapy-induced alopecia: a review of the literature.Cancer Nurs. 1984; 7: 221-228Crossref PubMed Google Scholar]. Telogen effluvium is the excessive shedding of hair caused by an increased proportion of follicles entering the telogen stage. Low levels of thyroxine cause telogen effluvium [2.Paus R. Control of the hair cycle and hair diseases as cycling disorders.Curr Opin Dermatol. 1996; 3: 248-258Google Scholar]. In our clinical case, the patient was hypothyroid during chemotherapy with paclitaxel, due to the cessation of thyroxine replacement. As a result, most hair follicles probably entered the telogen stage (Figure 1). We hypothesize that paclitaxel could not act in the hair follicles that were in the telogen stage and thus no alopecia appeared (Figure 1). Once thyroid function was restored, it is likely that the telogen stage was completed leading to telogen effluvium, and alopecia grade 2 developed. Another factor that may contribute to the development of alopecia is the possibility of paclitaxel accumulating in the scalp and causing anagen effluvium. Since an increase in the percentage of follicles in the telogen stage leads to excessive shedding and telogen effluvium, drugs that reduce the percentage of hair follicles in this stage or prevent the evolution of hair follicles to this stage could be valuable in treating hair loss [3.Lindner G. Botchkareva V.A. Botchkareva N.V. et al.Analysis of apoptosis during hair follicle regression.Am J Pathol. 1997; 151: 1601-1617PubMed Google Scholar, 5.Cline B.W. Prevention of chemotherapy-induced alopecia: a review of the literature.Cancer Nurs. 1984; 7: 221-228Crossref PubMed Google Scholar]. In conclusion, the above clinical case represents a very rareclinical phenomena that shows an interesting interaction of two different factors in the regulation of hair growth. The mechanism of action and interaction of various factors such as thyroid hormones and chemotherapeutic agents in the biological cycle of hair growth is still poorly understood. Progress in our understanding of the biology and pathophysiology of hair follicles should lead to more effective therapies for disorders of hair growth, including chemotherapy-induced alopecia.

The aim of this study was to evaluate the activity and safety of 5-fluorouracil (5-FU) / leucovorin (LV) and irinotecan as first- or second-line treatment in patients with advanced gastric adenocarcinoma. Treatment consisted of irinotecan 80 mg/m2 intravenously (i.v.), followed by LV 200 mg/m2 (i.v.) and 5-FU 450 mg/m2 as an i.v. bolus, administered weekly for 6 weeks, followed by a 2-week rest period. Thirty-one patients (23 chemo-naïve, 8 chemo-exposed) were enrolled. The overall response rate was 22.6% and the disease control rate was 38.7%. Among the patients who received the regimen as first-line treatment, objective response rate was 30.4% and the disease control rate was 52.1%. However, progression of the disease was recorded in all the patients receiving the combination as second-line chemotherapy. The median time to disease progression (TTP) was 4 months and the median duration of survival was 7 months. The median TTP was 6 months for patients treated with first-line chemotherapy and 2.5 for those who received study treatment as second line. Furthermore, the median survival duration was 8 months and 6 months, respectively. The most frequent grade 3 toxicity was febrile neutropenia. Grade 3 non-hematological toxicities were rare. There were no treatmentrelated deaths.The combination of 5-FU/LV and irinotecan as first-line treatment was found to be well tolerated and effective in patients with advanced gastric cancer. Further investigation would be worthwhile, particularly in elderly or debilitated patients who cannot tolerate aggressive chemotherapy.

The association between inflammatory bowel disease and colorectal cancer is well known. Ulcerative colitis is a risk factor for the development of colorectal cancer, and this risk increases with the activity and duration of bowel inflammation. Here we describe the case of a 52-year-old man who developed ulcerative colitis 6 years after the diagnosis and treatment of colon cancer. Although this could be a coincidence, there could be additional possibilities, like pre-existence of quiescent colitis, late effect of therapy, or maybe the existence of common pathogenetic factors contributing to the development of ulcerative colitis and colorectal cancer.

Breast cancer is a highly heterogeneous disease both at the histological and molecular levels. We have previously shown that RANK-c is a regulator of NF-κB signaling and exerts a suppressive effect on aggressive properties of ER negative breast cancer cells, while there is an opposite effect on ER positive cell lines. In order to identify molecular determinants that govern the opposing function of RANK-c in breast cancer cells we employed the two cell lines with the highest degree of phenotypic divergence upon RANK-c-expression (SKBR3 and BT474) and identified proteins that interact with RANK-c by affinity-enrichment mass spectrometry (AE-MS) analysis. Annotating enriched proteins with NF-κB signaling pathway revealed TRAF3 as an interacting partner of RANK-c in SKBR3 cell protein lysates, but not in BT474 breast cancer cells in which RANK-c induces cell aggressiveness. To determine the role of TRAF3 in the phenotype of BT474-RANK-c cells, we reconstructed the TRAF3/RANK-c interaction both in parental BT474 and RANK-c expressing cells and tested for aggressive properties through colony formation, migration and invasion assays. TRAF3 forced expression was able to reverse BT474 phenotypic changes imposed by RANK-c, rendering cells less aggressive. Finally, TRAF3 gene expression data and TRAF3 immunohistochemical (IHC) analysis on breast cancer samples indicated that TRAF3 expression correlates with Overall Survival (OS), Recurrence Free Survival (RFS) and several clinicopathological parameters (histological grade, proliferation index) of breast cancer disease.

Recently, the Patras Immunotherapy Score (PIOS) has been developed to estimate the survival benefit of patients with advanced non-small-cell lung cancer (aNSCLC) treated with nivolumab or pembrolizumab. The aim of this study was to validate the clinical value of PIOS in an external cohort of aNSCLC patients.PIOS is a baseline formula produced by the combination of performance status, body mass index, age and line of treatment. In this multicentre study, 626 patients with confirmed NSCLC pathology, who had been treated with nivolumab or pembrolizumab, as well as 444 patients with aNSCLC, who had been managed with chemotherapy alone, were retrospectively enrolled. Predictive and prognostic values of PIOS were finally evaluated.Patients treated with immunotherapy and higher PIOS score had an improved progression-free survival not only in univariate [hazard ratio (HR) = 0.621, p = 0.001], but also in multivariable analysis (HR = 0.651, p = 0.003). In addition, improved overall survival with increasing PIOS score was also observed (HR = 0.608, p < 0.001) with this association remaining statistically significant after adjusting for programmed-cell death ligand 1 (PD-L1) expression (HR = 0.620, p < 0.001). In addition, patients with disease progression (PD) had lower scores compared to those with stable disease (SD), partial response (PR) or complete response (CR) in a two-tier model (p < 0.001) as well as in a four-tier model (PD, SD, PR and CR; p < 0.001). Prognostic significance of PIOS score also persisted using a binary logistic regression analysis, adjusted for disease stage and PD-L1 status (p = 0.002, odds ratio: 0.578). Contrarily, PIOS had no prognostic significance in the chemotherapy group; however, upon combined analysis of the two cohorts, PIOS was found to have a significant interaction with the type of treatment (HR = 0.066 with p < 0.001), confirming its predictive value for immunotherapy.This study provides further validation of PIOS in aNSCLC patients treated with anti-PD-1 monotherapy.

&lt;i&gt;Purpose:&lt;/i&gt; In the present phase II study we evaluated the docetaxel-ifosfamide-carboplatin (DICb) combination in the outpatient setting in patients with advanced non-small-cell lung cancer (NSCLC). &lt;i&gt;Patients and Methods:&lt;/i&gt; Patients with advanced NSCLC (stages IIIB/IV), WHO performance status (PS) &lt;2, and no prior chemotherapy were eligible. Chemotherapy drug doses were: docetaxel: 80 mg/m&lt;sup&gt;2&lt;/sup&gt;, ifosfamide: 3.5 g/m&lt;sup&gt;2&lt;/sup&gt;, and carboplatin at a target area under the curve of 5 (based on Calvert’s formula), all on day 1, followed by prophylactic G-CSF. &lt;i&gt;Results:&lt;/i&gt; Fourty patients were entered and all are evaluable for response and toxicity: median age: 64 (48–72); PS: 1 (0–1); gender: 29 males/11 females; stages: IIIB: 13 (33%), IV: 27 (67%). Metastatic sites at diagnosis included: lymph nodes: 25; bone: 7; liver: 4; brain: 5; lung nodules: 13; adrenals: 6. Responses were as follows: 22/40 [55%; 95% confidence interval (CI), 54–81%] evaluable patients responded: 4 complete responses, 18 partial responses, 11 had stable disease, and 7 had progressive disease. The median response duration was 7 months (range 2–14 months), median time to progression 9 months (range 2–18 months) and median overall survival 11 months (range 3–46+ months). 1-year survival was 47.5%. Grade 3/4 toxicities included: neutropenia 28/40, with 12 developing grade 4 and 12% febrile neutropenia, thrombocytopenia grade 3: 3/40 and grade 4: 1/40, no grade 3 neuropathy, grade 1 CNS toxicity in 3, no renal toxicity, 8 grade 2 diarrhea and 4 grade 3 vomiting. &lt;i&gt;Conclusion:&lt;/i&gt; In the present phase II study the DICb combination yielded important activity and good tolerability in advanced NSCLC.

Teratomas with malignant transformation occur in a small proportion of patients with metastatic germ cell tumors treated with platinum-based chemotherapy. Chondrosarcoma has rarely been reported as a component of the second non-germ cell malignancy. We report the case of a 37-year-old man who developed a chondrosarcoma in a recurrent retroperitoneal mass after chemotherapy for testicular germ cell tumor. Malignant transformation of the retroperitoneal teratomatous mass occurred in the absence of any symptoms or clinical signs, elevation in serum tumor markers, or the presence of atypical elements in previously resected specimens, suggesting the need for close radiographic follow-up of these patients.

The macroscopic and microscopic features of 60 hepatocellular carcinomas (HCC) were investigated and correlated with patients' disease-free survival.The study included 60 HCCs removed, by partial hepatectomy, from an equal number of patients. In these tumors, several macroscopic and microscopic features were assessed, graded and correlated with disease-free survival.HCCs begin as small, well-differentiated tumors that have an increased proliferation rate and neovascularization. Vascular invasion, which is the strongest predictor of disease recurrence, correlated significantly with tumor number and size, the predominant and worst degree of differentiation, and the apoptosis/mitosis ratio. In the absence of macroscopic or large vessel invasion, the largest tumor size (p = 0.006), apoptosis/mitosis ratio (p = 0.03) and number of tumors (p = 0.04) were independent predictors of disease-free survival.This study showed that, in humans, the prognosis of HCC depends on several biological factors. Aggressive biological behavior (vascular invasion and recurrence) correlated significantly with: a) alterations in the apoptosis/mitosis ratio and b) architectural and cellular alterations.

829 Background: Gemcitabine and mitoxantrone have both been demonstrated significant antitumor activity in patients with breast cancer. The aim of the study was to evaluate the efficacy and safety of the combination as second or third line treatment in patients with advanced breast cancer (ABC). Methods: Fifty-six previously treated patients with ABC were enrolled from June 2000 to November 2002 and 46 were eligible. Mean age was 56 years (range 35–72) and ECOG performance status was <3. Sites of metastasis were as follows: liver 56%, bones 48%, lungs 46%, lymph nodes 17%. All patients received mitoxantrone 10mg/m2, D1 and gemcitabine 1000mg/m2, D1+8 every 21 days for 6 cycles. The relative dose intensity of mitoxantrone and gemcitabine was 0.76 and 0.77, respectively. A total of 211 cycles were delivered. Results: All patients were analyzed for toxicity for response. There were no complete responders. The objective response rate was 24% (95% confidence interval [CI] 12.6–38.8), 15 (33%) patients had stable disease, 15 (33%) had progressive disease and 4 (9%) were nonevaluable. At median follow up of 27.8 months overall survival was 13.3 months (range 0.6–33.8+) and the median time to disease progression was 4.4 months (range 0.2–33.8). Toxicities (grade III-IV) were as follows: leukopenia 18 (39%), neutropenia 19 (41%), thrombocytopenia 4 (8,5%), anemia 6 (13%) and alopecia 1 (2%). Febrile neutropenia was recorded in 2 (4%) patients. There were no treatment-related deaths. Conclusions: The combination of mitoxantrone and gemcitabine is an effective and well-tolerated regimen in pretreated patients with advanced breast cancer. No significant financial relationships to disclose.

5033 Background: The combination of carboplatin/paclitaxel represents the standard 1st-line chemotherapy in advanced OC, FC, and PPC. The optimal duration of paclitaxel treatment has not been defined, while its use is associated with cumulative neurotoxicity in about 50% of patients, which becomes long-term in 15-20% of cases. We, therefore, designed a randomized study to investigate the effect of administering 4 instead of 8 cycles of paclitaxel in the combination carboplatin/paclitaxel on efficacy and tolerability of this treatment. Methods: Patients with FIGO stages IIC-IV OC, FC, PPC were included. Carboplatin AUC 6 and paclitaxel at 175 mg/m 2 were used. Both agents were administered for 8 cycles in the CP8 arm, while paclitaxel was administered only for 4 cycles in the C8P4. The study was powered to detect a ± 15% difference in survival rate to a baseline rate of 50 % at the 3-year time point. Results: 389 pts were randomized (2/2004-1/2008) and 380 were eligible for analysis (CP8: 192, C8P4:188). The distribution (CP8 vs C8P4) of baseline characteristics were: stage III: 78% vs. 76%; IV: 12% vs. 15%, residual disease 0 cm: 25% vs. 22%, ECOG PS 0: 68% vs. 64%, serous carcinomas: 79% vs. 68%, tumor grade III: 56% vs. 63%. During a median follow up of 72.3 months 231 patients (111 [58%] in CP8 arm and 120 [64%] in the C8P4 arm) have died. Median PFS was significantly shorter in the C8P4 arm (21.41 vs. 16.46 months, HR [95% CI]: 1.36 [1.07-1.71], Wald’s p=0.011), while OS was similar between the two arms (53.41 vs. 46.59 months, HR [95% CI]: 1.18 [0.91-1.53], Wald’s p=0.211). Lower grade 3 or 4 neurotoxicity (1.9% vs. 10.8%, p&lt; 0.001) but higher myelotoxicity (neutropenia 38.8% vs. 28.8%, p=0.031; thrombocytopenia 20% vs. 8.3%, p=0.004) was observed in the C8P4 arm. Conclusions: Lowering the total number of cycles of paclitaxel in 1st-line chemotherapy of advanced OC, FC, PPC resulted in similar OS but shorter median PFS and is not recommended in this setting. The reduction of neurotoxicity by limiting the total paclitaxel cycles to 4 is achieved at the expense of higher myelotoxicity.

Background: Inoperable gastric and GEJ cancer is usually treated with platinum- and fluoropyrimidine-based combination chemotherapy. Targeting of the epidermal growth factor family of receptors has been unsuccessful except in the case of HER2 targeting with trastuzumab. Afatinib, has shown activity in preclinical models of gastric cancer and has been combined with cisplatin and 5-FU in phase I studies. Methods: Patients (pts) were treated with the combination of cisplatin (75 mg/m2 ; day 1), 5-FU (750 mg/m2; continuous infusion days 1-4) and afatinib (40 mg/day; week1: days 3-5, weeks 2, 3: days 1-5), in an effort to optimize therapy efficacy and tolerability. Primary endpoint was the objective response rate (ORR) in the intention to treat (ITT) and the per-protocol (PP) population. Secondary endpoints were progression-free survival (PFS), overall survival (OS), and safety profile. Results: Among the 55 pts (median age 64; range 20-77) enrolled (ITT), the ORR was 34.5% (44.2% in PP pts; N = 43). After a median follow-up of 33.3 months, median PFS and OS were 5 (95% CI 4-6; 49 relapses) and 9.3 (95% CI 6.7-11.5; 43 deaths) months, respectively. Median relative dose intensities administered were 0.97 for 5-FU, 0.96 for cisplatin and 0.94 for afatinib. Grade 3/4 adverse events (AEs) occurred in 34 pts (61.8%) and 9 pts (16.4%), respectively. Most common grade 3/4 AEs were neutropenia (27.3%), anemia (12.7%), hypokalemia (10.9%), diarrhea (5.4%), infections (5.4%). Acneiform rash grade 1/2 was noted in 20% of pts, while there were 4 (7.3%) thromboembolic events (grade 1-3). There were no treatment related deaths. Pts with GEJ cancers had worse OS than pts with gastric cancer (p = 0.03). Conclusions: The combination of afatinib with cisplatin / 5-FU in pts with inoperable gastric / GEJ cancer has modest activity, however afatinib weekend breaks optimized the compliance and tolerability of the combination. Identification of predictive biomarkers could potentially help in further evaluation of the role of afatinib in gastric / GEJ cancer. Clinical trial identification: NCT01743365 (December 6, 2012). Legal entity responsible for the study: Hellenic Cooperative Oncology Group. Funding: Hellenic Cooperative Oncology Group. Disclosure: All authors have declared no conflicts of interest.

8537 Background: Β-cell activating factor receptor (BAFFR) is a surface receptor, which leads to activation of the Nuclear Factor-kappaB (NF-κB) alternative pathway, a pathway with an important role in non-small cell lung cancer (NSCLC). In addition, cancer associated fibroblasts (CAFs) are major players of the tumor microenvironment promoting NSCLC. The aim of this study was to assess the possible associations of BAFFR expression in CAFs with response to first-line chemotherapy doublet and clinical outcome of NSCLC patients. Methods: Immunohistochemical analysis of BAFFR expression on CAFs was performed on tumor and tumor-adjacent formalin fixed and paraffin embedded tissue samples from 124 operated patients with NSCLC. Patients were under follow-up for at least 60 months, while response to chemotherapy was evaluated in patients who relapsed during this period. Results: BAFFR expression, which was noted exclusively in the cytoplasm of CAFs, was associated with OS only in patients with no infiltration of regional lymph nodes. Higher expression levels of BAFFR in CAFs were related to worse 2-, 3- and 5-year survival (P = 0.015, P = 0.027 and P = 0.040, respectively). This finding persisted after multivariate analysis with age, gender, histological subtype, histological differentiation and disease stage as coefficients (P = 0.009; HR, 2.734; 95% CI, 1.283-5.828). In addition, response to first line chemotherapy was associated with BAFFR expression in CAFs (P = 0.025). Patients who progressed had lower BAFFR levels. Furthermore, BAFFR expression in CAFs was associated with patients’ age. In particular, older patients had higher expression of BAFFR compared to patients younger than 55 years (P = 0.010). Additionally, carcinomas with better differentiation had lower expression of BAFFR in CAFs (P = 0.005). Finally, BAFFR expression in CAFs was related to development of metastatic disease (P = 0.033) and particularly in liver (P = 0,017) and in bones (P = 0.003). Conclusions: The present findings suggest that the expression of BAFFR in CAFs may be a useful biomarker with prognostic and predictive value, representing possibly an unknown biological relation, which merits further investigation.

e21507 Background: With the exception of programmed death ligand 1 (PD-L1) expression and Tumour Mutational Burden (TMB), which have entered clinical practice, no other clinically useful predictive biomarker for immune checkpoint inhibitors (ICIs) has been established in the daily practice. The purpose of this study was to develop a novel, non-interventional and clinically useful predictive score for NSCLC patients with advanced disease treated with ICIs. Methods: Eighty-nine patients with advanced and histologically confirmed NSCLC (stages III and IV), treated with immunotherapy (nivolumab, pembrolizumab, atezolizumab), were enrolled in the current study. Clinicopathological data as well response rates and clinical outcome data were collected. Based on this data and using a regression model, we developed a predictive score (Patras Immunotherapy Score-PIOS) with regard to the best response to ICIs. Best overall responses (BOR) were based on the immune-based therapeutics (iRECIST) criteria. Results: Four of the studied parameters -Performance Status (PS), Body Mass Index (BMI), age and lines of treatment (LOT)- were incorporated in our formula (PS *BMI/ LOT*age) giving rise to PIOS. This score was strongly associated with BOR, with patients of a good response (SD, PR or CR) having higher PIOS compared to patients with progression disease (PD) (p&lt;0.001). The association remained significant when we used a four-tier model (PD, SD, PR and CR) for BOR (p&lt;0.001). PIOS predictive significance also persisted using a binary logistic regression analysis (p=0.001). Conclusions: This study suggests that PIOS, which combines 4 baseline clinical parameters, may help to identify NSCLC patients with increased probability to be benefitted from ICIs treatment. Further evaluation and possibly combination with other factors may multiply its clinical significance.

Background Immune system-related receptors CD40 (tumor necrosis factor receptor superfamily member 5), BAFFR (tumor necrosis factor receptor superfamily member 13C), and LTβR (tumor necrosis factor receptor superfamily member 3) play a pivotal role in non-small-cell lung cancer (NSCLC). To further evaluate their role in NSCLC, CD40 rs1883832 (T&amp;gt;C), BAFFR rs7290134 (A&amp;gt;G), and LTβR rs10849448 (A&amp;gt;G) single-nucleotide polymorphisms (SNPs) were investigated regarding their impact in risk and clinical outcome of NSCLC patients. Methods The three selected SNPs were evaluated in 229 NSCLC patients and 299 healthy controls, while CD40, BAFFR, and LTβR protein expression was assessed by immunohistochemistry in 96 tumor specimens from NSCLC patients. Results In total, CD40 rs1883832 was associated with NSCLC risk, with the T allele, after adjusting for cofactors, being related to increased risk (p = 0.007; OR 1.701). Moreover, the CT genotype was associated with increased risk (p = 0.024; OR 1.606) and poorer 5-year overall survival (OS) after adjusting for cofactors (p = 0.001, HR 1.829), while CC was associated with higher CD40 expression in tumorous cells (p = 0.040) and in stromal cells (p = 0.036). In addition, AA homozygotes for the LTβR rs10849448 had increased risk for NSCLC in multivariate analysis (p = 0.008; OR, 2.106) and higher LTβR membranous expression (p = 0.035). Although BAFFR rs7290134 was associated with BAFFR membranous expression (p = 0.039), BAFFR rs7290134 was not associated with neither the disease risk nor the prognosis of NSCLC patients. Conclusions In conclusion, CD40 rs1883832 and LTβR rs10849448 seem to be associated with increased risk for NSCLC, while CD40 rs1883832 is also associated with OS of patients with NSCLC.

ABSTRACT Aim: Prophylactic erythropoiesis-stimulating agent (ESA) administration for chemotherapy-induced anemia (CIA) is not supported by current guidelines. Long-term follow-up of patients that had been treated with EPO for CIA in the past may provide useful information. Methods: In 2002 we undertook a prospective, randomized phase III trial of prophylactic versus hemoglobin (Hgb)-based (threshold: 12 mg/dl) ESA administration in patients with solid tumors and CIA, which was permanently suspended in 2005 in the view of published data at that time, while patient surveillance continued. Herein we present safety and efficacy outcomes after more than a decade of follow-up. Results: Among 630 evaluable patients, 40.1% were male, 50.9% had advanced cancer at diagnosis, 39.2% had Hgb levels Conclusions: Prophylactic administration of ESA for CIA in patients with solid tumors was associated with increased incidence of a composite of thrombosis-related adverse events, especially in patients receiving adjuvant treatment, but did not have a detrimental impact on relapse/progression and survival rates. Disclosure: All authors have declared no conflicts of interest.

Gastric cancer is a relatively common malignancy. Recently, the presence of the human epidermal growth factor receptor 2 (HER2) was identified as a molecular target in a proportion of patients who benefited from the addition of appropriate anti-HER2 treatments. Our study explored the clinical and prognostic role of known HER family members, human epidermal growth factor receptor 1 (EGFR or HER1), HER2, HER3 and HER4.Formalin-fixed paraffin-embedded (FFPE) tumor tissue samples from 249 gastric cancer patients were studied by immunohistochemistry for protein expression of EGFR, HER2, HER3 and HER4.Of the 249 evaluable patients, 32 did not have complete data of treatment details and/or follow-up and were excluded from the survival analyses. Of the 217 patients with complete treatment and follow-up data, 178 were operated and treated for early disease (group 1), while 39 for advanced disease (group 2). The frequency of positive EGFR, HER2, HER3 and HER4 protein expression in all patients was 17.5%, 11.8%, 14.8% and 32.9%, respectively. There were no differences in protein expression of any of the markers between the two groups. There were, however, statistically significant associations between HER4 and all other HER family members, as well as between HER2 and HER3 expression. Of note, EGFR-positive membranous protein expression was significantly associated with the presence of lymphovascular invasion (p=0.027) and HER3 and HER4 negative cytoplasmic protein expression with well/moderately-differentiated tumors (p=0.030 and p=0.014, respectively). None of the HER family members were of prognostic value for OS in univariate analysis.The present study confirmed the known protein expression frequencies of HER family members in gastric cancer in a Greek population. Several associations were observed among the HER family members and between clinicopathological characteristics and HER family members. Further research is needed on their exact prognostic role, as well as their therapeutic targeting.

ABSTRACT Aim: Tumour-associated immune response and colon cancer site emerge as parameters impacting on disease biology and patient outcome. Methods: mRNA gene expression of immune response (IR) genes (CD3Z, CD8, CXCL9, CXCL13, IGHM, FOXP3), SNAI2 and ESR1 were quantified by RTqPCR in formalin-fixed tumours of 408 oxaliplatin-treated patients with stage II/III colorectal cancer (trial ACTRN12610000509066). Results were submitted to hierarchical clustering and analysed. Results: We selected a mRNA gene signature (mRNA 2-cluster immunoscore, mIS2) based on CD3Z and CD8 expression (Cluster 2: upregulated CD3Z CD8 expression; Cluster 1: more heterogeneous but overall downregulated CD3Z CD8 expression). Partitioning analysis including age, stage, site, mIS2 and KRAS gene mutation, revealed that tumour stage, tumour site and mIS2 identified eight patient populations with distinct DFS (p MULTIVARIATE ANALYSIS HR for relapse P-value HR for death P-value STAGE_SITE_mIS2 0.0008 0.0008 Stage II Right mIS2-downreg 0.23 0.1702 0.17 0.09 Stage II Right mIS2-upreg 0.19 0.1188 0.00 0.98 Stage II Left mIS2-downreg 0.26 0.0466 0.22 0.02 Stage II Left mIS2-upreg 0.62 0.4803 0.46 0.25 Stage III Right mIS2-downreg 3.00 0.0152 2.62 0.02 Stage III Right mIS2-upreg 0.79 0.7355 1.50 0.43 Stage III Left mIS2-downreg 1.43 0.4001 1.04 0.91 Stage III Left mIS2-upreg 1 1 HIGH TUMOUR MRNA EXPRESSION OF ESR1 2.91 0.0003 1.95 0.02 PRESENCE OF NECROSIS 0.42 0.0068 0.39 0.002 Conclusions: The prognostic significance of tumour mRNA-based CD3 and CD8 immune response signature may be distinct in different stages and different sites of colon cancer. Disclosure: R. Wirtz: Stocks at Stratifyer Molecular Pathology, Cologne, Germany. All other authors have declared no conflicts of interest.

e13012 Background: Lung cancer remains the leading cause of cancer-related deaths worldwide. Recently, NF-kB2 was implicated in NSCLC pathogenesis. Here, we further studied the role of NF-kB2 in NSCLC by assessing the prognostic value of the single nucleotide polymorphisms (SNPs) rs7897947 (T/G) and rs12769316 (G/A). Methods: We genotyped 272 NSCLC patients and 279 healthy donors for the2 NF-kB2 SNPs. The enrolled patients were of stages I-IV and were medically managed at the University Hospital of Patras. Results: Rs7897947 TT homozygotes were associated with poorer overall survival (OS), compared to G allele carriers, after 2 and 3 years of observation (P = 0.013 and P = 0.033, respectively). These differences were pronounced for 2-, 3- and 5-year survival of stages III and IV patients (P = 0.001; HR, 2.271, P = 0.022; HR, 1.629 and P = 0.035; HR, 1.551, respectively), while no association was found regarding survival of stage I and II patients. The prognostic significance of the TT genotype for 2- and 3-year OS persisted in multivariate analysis (P = 0.030; HR, 1.591 and P = 0.028; HR, 1.503, respectively), but not in the 5-year follow-up (P = 0.069; HR, 1.360). Interestingly, rs7897947 was also associated with the OS of patients who received first-line chemotherapy (n = 69) with TT homozygotes displaying worse 2- or 3-year OS (P = 0.006; HR, 2.576 and P = 0.014; HR, 2.064, respectively). In addition, rs12769316 was related to OS of stage I and II patients. In particular, stage I A allele carriers were associated with worse 3-year OS not only in univariate (P = 0.031; HR, 2.426), but also in multivariate analysis (P = 0.047; HR, 2.353). Interestingly, stage II GG homozygotes displayed worse 5-year survival compared to A allele carriers in univariate analysis (P = 0.006; HR, 3.049) and in multivariate analysis (P = 0.029; HR, 3.022), reflecting a possible relation with the different treatment approaches of the two stages. Conclusions: The present study suggests that rs7897947 and rs12769316 SNPs may be useful as independent prognostic biomarkers in NSCLC.

e13011 Background: Breast cancer is the most common malignancy, affecting one in eight women in North America and Europe. The human epidermal growth factor receptor (EGFR) protein is a type I transmembrane receptor that comprise a major determinant of normal development but also cancer. RANK receptor (Receptor Activator of Nuclear factor-kB) is a tumor necrosis superfamily member and binding partner for RANKL, which was recently implicated in breast cancer initiation, progression and metastasis. Here we provide preliminary evidence of a possible interplay between RANK and EGFR signaling in breast cancer. Methods: TCGA (cancergenome.nih.gov) publicly available mRNA and protein expression data (RNA Seq V2 RSEM) for EGFR and TNFSRF11A (RANK) genes from an unselected cohort of 1036 breast cancer patients and 58 breast cancer cell lines were retrieved and analyzed. EGFR and TNFSRF11A mRNA expression were also evaluated through real-time RT-PCR in a panel of 7 human breast cancer cell lines and 22 FFPE breast cancer samples. Plasmid transfections and western blots were performed to evaluate EGFR and RANK downstream signaling after EGF stimulation. Results: Between the four family members of ErbB (EGFR, ERBB2/3/4) receptors, RANK mRNA showed a statistically significant positive correlation (p< 0.001) with the mRNA and protein expression of EGFR, but not with ERBB2/3/4. The same positive mRNA correlation was observed in between the 58 CCLE breast cancer cell lines, seven in house breast cancer cell lines and 22 FFPE cases. RANK plasmid transfection and western blotting revealed a significant upregulation of ERK (pp44/42) signaling after EGF stimulation in cell lines. Finally, further analyses of survival data of a group of breast cancer patients (n = 248) from TCGA, revealed an EGFRhi RANKhi subpopulation that showed a statistically significant (p= 0.001) reduced overall survival when compared to EGFRlowRANKlowgroup of patients. Conclusions: In this study we provide preliminary evidence that RANK is co-expressed with EGFR in a subset of breast cancer patients, with worse clinical outcome. RANK and EGFR co-expression in cell lines seems to augment EGF-induced ERK signaling, giving raise to the possibility of simultaneous therapeutic targeting of RANK/EGFR in breast cancer.